Healthcare Provider Details

I. General information

NPI: 1790713568
Provider Name (Legal Business Name): CHARLES FREDERICK LACY PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 SUNSET WAY
HENDERSON NV
89014-2333
US

IV. Provider business mailing address

1017 LAVENDER LN
LA CANADA CA
91011-2338
US

V. Phone/Fax

Practice location:
  • Phone: 702-968-2016
  • Fax: 702-990-4435
Mailing address:
  • Phone: 702-968-2016
  • Fax: 702-990-4435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number36613
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: