Provider Demographics
NPI:1831400522
Name:DETHLEFSEN, MEGAN R (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MEGAN
Middle Name:R
Last Name:DETHLEFSEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:MEGAN
Other - Middle Name:R
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:1306 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:NE
Mailing Address - Zip Code:68818-3021
Mailing Address - Country:US
Mailing Address - Phone:308-233-4847
Mailing Address - Fax:
Practice Address - Street 1:2201 N BROADWELL AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-2153
Practice Address - Country:US
Practice Address - Phone:308-382-3660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13421183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist