Basic Information
| Provider Information | |||||||||
| NPI: | 1316553787 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLIAM | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 961 | ||||||||
| Address2: | |||||||||
| City: | KEAMS CANYON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860340961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167840767 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | MILE POST 288 HWY 264 | ||||||||
| Address2: | |||||||||
| City: | POLACCA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287376000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2020 | ||||||||
| LastUpdateDate: | 09/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 27421 | MD | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 27421 | 01 | MD | MARYLAND BOARD OF PHARMACY | OTHER |