Provider Demographics
NPI:1336846351
Name:BUCKHANNON, LACEY DEYANNE
Entity Type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:DEYANNE
Last Name:BUCKHANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:DEYANNE
Other - Last Name:HUMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:480 MACON ST
Mailing Address - Street 2:
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853-9421
Mailing Address - Country:US
Mailing Address - Phone:217-721-8731
Mailing Address - Fax:
Practice Address - Street 1:1509 S NEIL ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-6580
Practice Address - Country:US
Practice Address - Phone:217-351-1516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL049137234183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician