Provider Demographics
NPI:1144820861
Name:COLBERT, JOHN MICHAEL
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:COLBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 APRICOT LN
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-8688
Mailing Address - Country:US
Mailing Address - Phone:740-988-6959
Mailing Address - Fax:
Practice Address - Street 1:100 WALMART DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-8692
Practice Address - Country:US
Practice Address - Phone:740-286-6860
Practice Address - Fax:740-286-6261
Is Sole Proprietor?:No
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH16403183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist