Provider Demographics
NPI:1114202280
Name:LIVINGSTON, DANA SUE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:DANA
Middle Name:SUE
Last Name:LIVINGSTON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 DOERR ST
Mailing Address - Street 2:
Mailing Address - City:ROXANA
Mailing Address - State:IL
Mailing Address - Zip Code:62084-1114
Mailing Address - Country:US
Mailing Address - Phone:618-251-9195
Mailing Address - Fax:
Practice Address - Street 1:550 W SAINT LOUIS AVE
Practice Address - Street 2:
Practice Address - City:EAST ALTON
Practice Address - State:IL
Practice Address - Zip Code:62024-1044
Practice Address - Country:US
Practice Address - Phone:618-258-0350
Practice Address - Fax:618-258-6025
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34475183500000X
IL051-287430183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist