Provider Demographics
NPI:1366423139
Name:DAVID L & HENRIETTA F COLE
Entity type:Organization
Organization Name:DAVID L & HENRIETTA F COLE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:610-539-7282
Mailing Address - Street 1:2113 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19403-3005
Mailing Address - Country:US
Mailing Address - Phone:610-539-7283
Mailing Address - Fax:610-539-6430
Practice Address - Street 1:2113 W MAIN ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:PA
Practice Address - Zip Code:19403-3005
Practice Address - Country:US
Practice Address - Phone:610-539-7283
Practice Address - Fax:610-539-6430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PA3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0185531Medicaid
PA0005637970002Medicaid
PA3936121OtherNCPDP #
PA3936121OtherNCPDP #
PA0005637970002Medicaid