Provider Demographics
NPI:1487991170
Name:COLOSIMO, MARK STEVEN (RPH)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
Last Name:COLOSIMO
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 1:92 PEBBLE LAKE LN
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-0540
Mailing Address - Country:US
Mailing Address - Phone:904-228-4982
Mailing Address - Fax:
Practice Address - Street 1:13820 OLD ST AUGUSTINE ROAD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258
Practice Address - Country:US
Practice Address - Phone:904-262-5446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 20924183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist