MEDICARE: COLLEY DISCOUNT PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	0201002209	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2102952	OTHER		PK

General Provider Information

NPI Number	:	1619982212
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLLEY DISCOUNT PHARMACY INC

Provider Business Mailing Address
First Line	:	1415 COLLEY AVE
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23517-1705
Country	:	US
Telephone Number	:	757-622-2757
Fax Number	:	757-640-0367

Provider Business Practice Location Address
First Line	:	1415 COLLEY AVE
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23517-1705
Country	:	US
Telephone Number	:	757-622-2757
Fax Number	:	757-640-0367

Authorized Official
Title or Position	:	OWNER
Name	:	STEPHAN BUCHBERG
Credential	:
Telephone Number	:	757-622-2757

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	09/28/2016

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