Provider Demographics
NPI:1104508589
Name:MEDFORD, KATIE ANN (PHARMD)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:ANN
Last Name:MEDFORD
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19714 JONES RD
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-6823
Mailing Address - Country:US
Mailing Address - Phone:618-444-8310
Mailing Address - Fax:
Practice Address - Street 1:2712 GODFREY RD
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-3311
Practice Address - Country:US
Practice Address - Phone:618-466-0825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023030688183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist