Provider Demographics
NPI:1063130680
Name:COLGROVE, ZACKERY RAY (PHARMD)
Entity type:Individual
Prefix:
First Name:ZACKERY
Middle Name:RAY
Last Name:COLGROVE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S 31ST AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68105-1484
Mailing Address - Country:US
Mailing Address - Phone:402-594-3581
Mailing Address - Fax:
Practice Address - Street 1:4405 N 72ND ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68134-2350
Practice Address - Country:US
Practice Address - Phone:402-571-3122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17626183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist