=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942213905
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES FRANCIS LUSTICK RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10535 HOSPITAL WAY
-----------------------------------------------------
City | MATHER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95655-4200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-600-8279
-----------------------------------------------------
Fax | 866-600-5321
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12730 FIG RD
-----------------------------------------------------
City | WILTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95693-9674
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-687-0639
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 15168
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------