Provider Demographics
NPI:1275205304
Name:MCGILL, DEMETRIA
Entity Type:Individual
Prefix:
First Name:DEMETRIA
Middle Name:
Last Name:MCGILL
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 1:3243 W 115TH ST
Mailing Address - Street 2:
Mailing Address - City:MERRIONETTE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60803-4555
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3243 W 115TH ST
Practice Address - Street 2:
Practice Address - City:MERRIONETTE PARK
Practice Address - State:IL
Practice Address - Zip Code:60803-4555
Practice Address - Country:US
Practice Address - Phone:708-389-9021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051304308183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist