Healthcare Provider Details

I. General information

NPI: 1619173556
Provider Name (Legal Business Name): COLOMA PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6577 PAW PAW AVE
COLOMA MI
49038-8805
US

IV. Provider business mailing address

6577 PAW PAW AVE
COLOMA MI
49038-8805
US

V. Phone/Fax

Practice location:
  • Phone: 269-468-6207
  • Fax: 269-468-6707
Mailing address:
  • Phone: 269-468-6207
  • Fax: 269-468-6707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number5301008639
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301008639
License Number StateMI

VIII. Authorized Official

Name: ASHABEN PATEL
Title or Position: OWNER
Credential:
Phone: 269-468-6207