Provider Demographics
NPI:1316725179
Name:BOYD, CHANTEAL LAQUITA
Entity type:Individual
Prefix:
First Name:CHANTEAL
Middle Name:LAQUITA
Last Name:BOYD
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 1:6333 RAIBLE DR
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38053-3672
Mailing Address - Country:US
Mailing Address - Phone:901-581-9321
Mailing Address - Fax:
Practice Address - Street 1:4015 AUSTIN PEAY HWY
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-2503
Practice Address - Country:US
Practice Address - Phone:901-373-4575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN47525183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist