Provider Demographics
NPI:1316553787
Name:GILLIAM, MEGAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 961
Mailing Address - Street 2:
Mailing Address - City:KEAMS CANYON
Mailing Address - State:AZ
Mailing Address - Zip Code:86034-0961
Mailing Address - Country:US
Mailing Address - Phone:516-784-0767
Mailing Address - Fax:
Practice Address - Street 1:MILE POST 288 HWY 264
Practice Address - Street 2:
Practice Address - City:POLACCA
Practice Address - State:AZ
Practice Address - Zip Code:86042
Practice Address - Country:US
Practice Address - Phone:928-737-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD27421183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD27421OtherMARYLAND BOARD OF PHARMACY