Provider Demographics
NPI:1437753597
Name:KINGMA, REBECCA (PHARMD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:KINGMA
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 1:19900 S LA GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8674
Mailing Address - Country:US
Mailing Address - Phone:708-478-1821
Mailing Address - Fax:708-478-3359
Practice Address - Street 1:19900 S LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8674
Practice Address - Country:US
Practice Address - Phone:708-478-1821
Practice Address - Fax:708-478-3359
Is Sole Proprietor?:No
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051293590183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist