Provider Demographics
NPI:1164924361
Name:COLLEY, CHARLES DAVID (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:DAVID
Last Name:COLLEY
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 1:1134 CAESARS CT
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70611-6739
Mailing Address - Country:US
Mailing Address - Phone:337-217-1524
Mailing Address - Fax:
Practice Address - Street 1:1514 SAMPSON ST # 1
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:LA
Practice Address - Zip Code:70669-4632
Practice Address - Country:US
Practice Address - Phone:337-433-1742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-02
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016137183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist