Provider Demographics
NPI:1770941825
Name:COLORECTAL PHARMACY INC
Entity type:Organization
Organization Name:COLORECTAL PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-935-0331
Mailing Address - Street 1:2500 HOSPITAL BLVD
Mailing Address - Street 2:SUITE 150-A
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4907
Mailing Address - Country:US
Mailing Address - Phone:678-935-0331
Mailing Address - Fax:678-935-0353
Practice Address - Street 1:2500 HOSPITAL BLVD
Practice Address - Street 2:SUITE 150-A
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4907
Practice Address - Country:US
Practice Address - Phone:678-935-0331
Practice Address - Fax:678-935-0353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-03
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0102653336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2157931OtherPK