Provider Demographics
NPI:1194231985
Name:COLLA, JENNIFER J (BSPHARM)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:COLLA
Suffix:
Gender:F
Credentials:BSPHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 LEALAND AVE
Mailing Address - Street 2:
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-1418
Mailing Address - Country:US
Mailing Address - Phone:330-774-4484
Mailing Address - Fax:
Practice Address - Street 1:307 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-4702
Practice Address - Country:US
Practice Address - Phone:330-758-2824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-16
Last Update Date:2017-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03122370183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist