Provider Demographics
NPI:1629479720
Name:FOLSOM, LACEY
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:FOLSOM
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:PO BOX 211
Mailing Address - Street 2:
Mailing Address - City:STAR LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:13690-0211
Mailing Address - Country:US
Mailing Address - Phone:315-848-3784
Mailing Address - Fax:315-848-5129
Practice Address - Street 1:4057 STATE HIGHWAY 3
Practice Address - Street 2:
Practice Address - City:STAR LAKE
Practice Address - State:NY
Practice Address - Zip Code:13690-3172
Practice Address - Country:US
Practice Address - Phone:315-848-3784
Practice Address - Fax:315-848-5129
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI 20 050800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist