Provider Demographics
NPI:1104939263
Name:COLETTA, SAMUEL J (RPH)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:J
Last Name:COLETTA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-1042
Mailing Address - Country:US
Mailing Address - Phone:859-750-4975
Mailing Address - Fax:
Practice Address - Street 1:118 6TH AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:KY
Practice Address - Zip Code:41074-1112
Practice Address - Country:US
Practice Address - Phone:859-491-1700
Practice Address - Fax:859-491-7680
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9590183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9590OtherKENTUCKY PHARMACIST LICEN
KY9590OtherKENTUCKY PHARMACIST LICEN