Provider Demographics
NPI:1245830744
Name:DEWITT, MEGAN
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:DEWITT
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 1:1155 HEAVENS GATE
Mailing Address - Street 2:
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156-4874
Mailing Address - Country:US
Mailing Address - Phone:224-401-2826
Mailing Address - Fax:
Practice Address - Street 1:1100 S RANDALL RD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4109
Practice Address - Country:US
Practice Address - Phone:847-468-9696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051299644183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist