Provider Demographics
NPI:1588920656
Name:COLETTA, MICHAEL ANTHONY (RPH)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANTHONY
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 1:505 VALLEY FORGE TRL
Mailing Address - Street 2:
Mailing Address - City:ROCKTON
Mailing Address - State:IL
Mailing Address - Zip Code:61072-3030
Mailing Address - Country:US
Mailing Address - Phone:815-979-0458
Mailing Address - Fax:
Practice Address - Street 1:1309 N HIGH ST
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1255
Practice Address - Country:US
Practice Address - Phone:920-563-6658
Practice Address - Fax:920-563-0156
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1397440183500000X
MO2003000291183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist