Provider Demographics
NPI:1932704616
Name:HUBER, DYLAN ZACHARY SAUL
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:ZACHARY SAUL
Last Name:HUBER
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 1:107 W GREEN ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-5282
Mailing Address - Country:US
Mailing Address - Phone:217-355-8123
Mailing Address - Fax:
Practice Address - Street 1:107 W GREEN ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-5282
Practice Address - Country:US
Practice Address - Phone:217-355-8123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051303295183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist