Provider Demographics
NPI:1235616087
Name:FETZKO, CHARLOTTE (PHARMD)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:FETZKO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 BARRETT ST APT 3079
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-1713
Mailing Address - Country:US
Mailing Address - Phone:518-894-2859
Mailing Address - Fax:
Practice Address - Street 1:555 HUBBARD AVE
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-3876
Practice Address - Country:US
Practice Address - Phone:413-442-7696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH236247183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist