Provider Demographics
NPI:1235406133
Name:JENKINS, LUCIUS
Entity Type:Individual
Prefix:MR
First Name:LUCIUS
Middle Name:
Last Name:JENKINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9808 S BEVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1377
Mailing Address - Country:US
Mailing Address - Phone:773-575-1031
Mailing Address - Fax:773-238-3472
Practice Address - Street 1:1633 W 95TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1331
Practice Address - Country:US
Practice Address - Phone:773-445-9277
Practice Address - Fax:773-445-3015
Is Sole Proprietor?:No
Enumeration Date:2011-11-20
Last Update Date:2011-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051035486183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist