Provider Demographics
NPI:1386718351
Name:COLPHARM, INC.
Entity type:Organization
Organization Name:COLPHARM, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:EARLE
Authorized Official - Last Name:BIRTH
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:570-458-5573
Mailing Address - Street 1:PO BOX 477
Mailing Address - Street 2:538 STATE STREET
Mailing Address - City:MILLVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17846-0477
Mailing Address - Country:US
Mailing Address - Phone:570-458-5573
Mailing Address - Fax:570-458-6113
Practice Address - Street 1:5 MOUNTAIN MALL
Practice Address - Street 2:SUITE 2
Practice Address - City:SHICKSHINNY
Practice Address - State:PA
Practice Address - Zip Code:18655-1227
Practice Address - Country:US
Practice Address - Phone:570-542-2420
Practice Address - Fax:570-542-2396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP412844L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPP412488LOtherSTATE PHARMACY LICENSE
PA1016460820001Medicaid
PA1026460001Medicare ID - Type Unspecified