=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114096450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLONIAL PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2006
-----------------------------------------------------
Last Update Date | 12/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7510 MECHANICSVILLE TPKE
-----------------------------------------------------
City | MECHANICSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23111-2144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-746-7997
-----------------------------------------------------
Fax | 804-746-5669
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7510 MECHANICSVILLE TPKE
-----------------------------------------------------
City | MECHANICSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23111-2144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-746-7997
-----------------------------------------------------
Fax | 804-746-5669
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE
-----------------------------------------------------
Name | MATTHEW BENNETT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-746-7997
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 0201002983
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------