Provider Demographics
NPI:1245562834
Name:LACEK, GEORGE JOSEPH JR (RPH)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:JOSEPH
Last Name:LACEK
Suffix:JR
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 1:149 WICKHAM AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-3721
Mailing Address - Country:US
Mailing Address - Phone:845-342-5566
Mailing Address - Fax:845-342-4986
Practice Address - Street 1:149 WICKHAM AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-3721
Practice Address - Country:US
Practice Address - Phone:845-342-5566
Practice Address - Fax:845-342-4986
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033395183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist