Healthcare Provider Details

I. General information

NPI: 1043573587
Provider Name (Legal Business Name): CHARLEMAGNE LACZA MS, PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 06/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2823 FRESNO ST
FRESNO CA
93721-1324
US

IV. Provider business mailing address

1362 CARLTON DR
GLENDALE CA
91205-1421
US

V. Phone/Fax

Practice location:
  • Phone: 559-459-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number60372
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI03193300
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number49194
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: