Provider Demographics
NPI:1578936431
Name:FETROW, CHARLES WILLIAM (PHARMD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:WILLIAM
Last Name:FETROW
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5135 PINA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-7896
Mailing Address - Country:US
Mailing Address - Phone:561-601-4951
Mailing Address - Fax:
Practice Address - Street 1:1381 S PATRICK DR
Practice Address - Street 2:STE A
Practice Address - City:PATRICK AFB
Practice Address - State:FL
Practice Address - Zip Code:32925-3606
Practice Address - Country:US
Practice Address - Phone:321-494-8216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-01
Last Update Date:2015-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 453491835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist