Healthcare Provider Details

I. General information

NPI: 1629187257
Provider Name (Legal Business Name): TINA MARIE KOLASA RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1019 RIVER ST SUITE #1
BELLEVILLE WI
53508-9181
US

IV. Provider business mailing address

1019 RIVER ST STE 1
BELLEVILLE WI
53508-9181
US

V. Phone/Fax

Practice location:
  • Phone: 608-424-3364
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number12237-040
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP038010L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: