Provider Demographics
NPI:1801497789
Name:VADUKUMCHERRY, JUSTIN (PHARMD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:VADUKUMCHERRY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 W WHITE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-6423
Mailing Address - Country:US
Mailing Address - Phone:217-698-5938
Mailing Address - Fax:
Practice Address - Street 1:2300 W WHITE OAKS DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-6423
Practice Address - Country:US
Practice Address - Phone:217-698-5938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051302865183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist