Provider Demographics
NPI:1003195330
Name:CHITLA, DOREELIN MENDOZA
Entity Type:Individual
Prefix:
First Name:DOREELIN
Middle Name:MENDOZA
Last Name:CHITLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12305 CAMBERWELL CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-8933
Mailing Address - Country:US
Mailing Address - Phone:919-600-2093
Mailing Address - Fax:
Practice Address - Street 1:3422 US HWY 1
Practice Address - Street 2:
Practice Address - City:FRANKLINTON
Practice Address - State:NC
Practice Address - Zip Code:27525
Practice Address - Country:US
Practice Address - Phone:919-494-7735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12216183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist