Healthcare Provider Details

I. General information

NPI: 1083893440
Provider Name (Legal Business Name): COLEEN MARIE RADOCAJ RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2007
Last Update Date: 11/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 N WELLWOOD AVE
LINDENHURST NY
11757-1634
US

IV. Provider business mailing address

15168 23RD AVE
WHITESTONE NY
11357-3721
US

V. Phone/Fax

Practice location:
  • Phone: 631-957-2720
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number048738
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: