Provider Demographics
NPI:1164791323
Name:DYKSTRA, SADIE ELIZABETH (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SADIE
Middle Name:ELIZABETH
Last Name:DYKSTRA
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 1:609 E BURKWOOD CT
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-5907
Mailing Address - Country:US
Mailing Address - Phone:217-369-3690
Mailing Address - Fax:
Practice Address - Street 1:2402 VILLAGE GREEN PL
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-7681
Practice Address - Country:US
Practice Address - Phone:217-398-2764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-16
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-288394183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist