Provider Demographics
NPI:1104280494
Name:CHARBONEAU, MARY ALICE (RPH)
Entity type:Individual
Prefix:MISS
First Name:MARY
Middle Name:ALICE
Last Name:CHARBONEAU
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 SEACLIF DR
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003
Mailing Address - Country:US
Mailing Address - Phone:707-337-7219
Mailing Address - Fax:
Practice Address - Street 1:80 RANCH DEL MAR
Practice Address - Street 2:
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003
Practice Address - Country:US
Practice Address - Phone:831-688-6417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARP55349183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist