Provider Demographics
NPI:1497257638
Name:CHARLY, SOSAMMA
Entity Type:Individual
Prefix:MRS
First Name:SOSAMMA
Middle Name:
Last Name:CHARLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:337 JACKRABBIT DR
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-8419
Mailing Address - Country:US
Mailing Address - Phone:760-592-4162
Mailing Address - Fax:
Practice Address - Street 1:2540 ROCKWOOD AVE
Practice Address - Street 2:
Practice Address - City:CALEXICO
Practice Address - State:CA
Practice Address - Zip Code:92231-4406
Practice Address - Country:US
Practice Address - Phone:760-768-5011
Practice Address - Fax:760-768-1059
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-04
Last Update Date:2018-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH47010183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist