Provider Demographics
NPI:1902808819
Name:COLUCCI, VINCENT J (PHARMD, BCPS)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:J
Last Name:COLUCCI
Suffix:
Gender:M
Credentials:PHARMD, BCPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5190 GOODAN LN
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-9076
Mailing Address - Country:US
Mailing Address - Phone:406-549-5846
Mailing Address - Fax:406-243-4353
Practice Address - Street 1:500 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4003
Practice Address - Country:US
Practice Address - Phone:406-329-7482
Practice Address - Fax:406-329-7219
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT29691835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTMC1145007OtherDEA LICENSE