Provider Demographics
NPI:1194201319
Name:SACKMANN, KAYCILEE
Entity Type:Individual
Prefix:
First Name:KAYCILEE
Middle Name:
Last Name:SACKMANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18034 US HIGHWAY 67
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-6900
Mailing Address - Country:US
Mailing Address - Phone:618-610-1831
Mailing Address - Fax:
Practice Address - Street 1:12921 ENTERPRISE WAY
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-1206
Practice Address - Country:US
Practice Address - Phone:618-610-1831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017029293183500000X
IL051.300854183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist