Healthcare Provider Details

I. General information

NPI: 1114096450
Provider Name (Legal Business Name): COLONIAL PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 12/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7510 MECHANICSVILLE TPKE
MECHANICSVILLE VA
23111-2144
US

IV. Provider business mailing address

7510 MECHANICSVILLE TPKE
MECHANICSVILLE VA
23111-2144
US

V. Phone/Fax

Practice location:
  • Phone: 804-746-7997
  • Fax: 804-746-5669
Mailing address:
  • Phone: 804-746-7997
  • Fax: 804-746-5669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0201002983
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW BENNETT
Title or Position: PHARMACIST IN CHARGE
Credential:
Phone: 804-746-7997