Provider Demographics
NPI:1700134509
Name:FEDERMAN, MEGHAN
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:
Last Name:FEDERMAN
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:PO BOX 2177
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-2177
Mailing Address - Country:US
Mailing Address - Phone:706-495-5837
Mailing Address - Fax:
Practice Address - Street 1:1520 WALTON WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-3702
Practice Address - Country:US
Practice Address - Phone:706-724-0598
Practice Address - Fax:706-724-6827
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13502183500000X
GA026107183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist