Basic Information
Provider Information | |||||||||
NPI: | 1568805133 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHARGUALAF | ||||||||
FirstName: | LAURA | ||||||||
MiddleName: | MINCEMOYER | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 101 MANNING DRIVE | ||||||||
Address2: | MEMORIAL HOSPITAL 4TH FLOOR | ||||||||
City: | CHAPEL HILL | ||||||||
State: | NC | ||||||||
PostalCode: | 27514 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9849747914 | ||||||||
FaxNumber: | 4342447553 | ||||||||
Practice Location | |||||||||
Address1: | 101 MANNING DRIVE | ||||||||
Address2: | MEMORIAL HOSPITAL 4TH FLOOR | ||||||||
City: | CHAPEL HILL | ||||||||
State: | NC | ||||||||
PostalCode: | 27514 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9849745100 | ||||||||
FaxNumber: | 9849745595 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/12/2013 | ||||||||
LastUpdateDate: | 08/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P2201X | 24639 | NC | Y |   |   |   |   |
No ID Information.