Provider Demographics
NPI:1790713568
Name:LACY, CHARLES FREDERICK (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:FREDERICK
Last Name:LACY
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 1:1017 LAVENDER LN
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011-2338
Mailing Address - Country:US
Mailing Address - Phone:702-968-2016
Mailing Address - Fax:702-990-4435
Practice Address - Street 1:11 SUNSET WAY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-2333
Practice Address - Country:US
Practice Address - Phone:702-968-2016
Practice Address - Fax:702-990-4435
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA366131835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy