Healthcare Provider Details

I. General information

NPI: 1477155117
Provider Name (Legal Business Name): PAUL F COLETTI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 S RANDALL RD
ALGONQUIN IL
60102-5919
US

IV. Provider business mailing address

1471 WHITE CHAPEL LN
ALGONQUIN IL
60102-6010
US

V. Phone/Fax

Practice location:
  • Phone: 847-458-5735
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number051038494
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: