Basic Information
| Provider Information | |||||||||
| NPI: | 1780746867 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLFAX PHARMACY LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | COLFAX PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 101 NORTH WALNUT STREET | ||||||||
| Address2: | |||||||||
| City: | COLFAX | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5156743503 | ||||||||
| FaxNumber: | 5456743530 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 NORTH WALNUT STREET | ||||||||
| Address2: | |||||||||
| City: | COLFAX | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5156743503 | ||||||||
| FaxNumber: | 5456743530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 09/09/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | ALPESH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8133042221 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 333600000X | 1580 | IA | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2164105 | 01 | PK | OTHER |