Healthcare Provider Details

I. General information

NPI: 1437184926
Provider Name (Legal Business Name): COLONIAL HEALTH PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 AVON AVE
NEWARK NJ
07108-2531
US

IV. Provider business mailing address

125 AVON AVE
NEWARK NJ
07108-2531
US

V. Phone/Fax

Practice location:
  • Phone: 973-824-5010
  • Fax: 973-799-0066
Mailing address:
  • Phone: 973-824-5010
  • Fax: 973-799-0066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28RS00571100
License Number StateNJ

VIII. Authorized Official

Name: LATCHMAN RAGHUNADAN
Title or Position: MANG
Credential: BS
Phone: 973-824-5010