Healthcare Provider Details

I. General information

NPI: 1851360614
Provider Name (Legal Business Name): LAURA CHURGOVICH FAHRENBROOK R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 01/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 EXEMPLA CIR
LAFAYETTE CO
80026-3370
US

IV. Provider business mailing address

PO BOX 16582
GOLDEN CO
80402-6009
US

V. Phone/Fax

Practice location:
  • Phone: 720-536-7888
  • Fax:
Mailing address:
  • Phone: 303-235-2762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number15322
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: