Provider Demographics
NPI:1548859325
Name:COLSON, ALICE CARDIN (DPH)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:CARDIN
Last Name:COLSON
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 SOUTHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BLOUNTVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37617-4877
Mailing Address - Country:US
Mailing Address - Phone:423-963-4539
Mailing Address - Fax:
Practice Address - Street 1:128 W STONE DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3221
Practice Address - Country:US
Practice Address - Phone:423-963-4539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202208687183500000X
TN9697183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist