Provider Demographics
NPI:1457989824
Name:WENDELSCHAFER, MEGAN
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:WENDELSCHAFER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:MARIE
Other - Last Name:HEEPKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4007 ROCKLEDGE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61705-8736
Mailing Address - Country:US
Mailing Address - Phone:608-558-1194
Mailing Address - Fax:
Practice Address - Street 1:1130 S VETERANS PKWY
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-7117
Practice Address - Country:US
Practice Address - Phone:309-661-1839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-31
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-296246183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist