Provider Demographics
NPI:1083202584
Name:CHARBONNEAU, LACEY MIKELLE (PHARMD, BCGP)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:MIKELLE
Last Name:CHARBONNEAU
Suffix:
Gender:F
Credentials:PHARMD, BCGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 6TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4062
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 6TH ST NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4062
Practice Address - Country:US
Practice Address - Phone:904-993-3592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-09
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS53336183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist