Provider Demographics
NPI:1629747035
Name:RAYSOR, MEGAN RENEA (RPH)
Entity Type:Individual
Prefix:DR
First Name:MEGAN
Middle Name:RENEA
Last Name:RAYSOR
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 CHURCHILL RD APT 203
Mailing Address - Street 2:
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853-8304
Mailing Address - Country:US
Mailing Address - Phone:804-877-3737
Mailing Address - Fax:
Practice Address - Street 1:255 W 1ST DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-5205
Practice Address - Country:US
Practice Address - Phone:217-428-1778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051304235183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist