Provider Demographics
NPI:1134400724
Name:LICINA, CHRISTINE KATHERINE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:KATHERINE
Last Name:LICINA
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 1:202 CARLISLE CT
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-7531
Mailing Address - Country:US
Mailing Address - Phone:630-551-4157
Mailing Address - Fax:
Practice Address - Street 1:3401 ORCHARD RD
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-5005
Practice Address - Country:US
Practice Address - Phone:630-551-0367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-039350183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist