Provider Demographics
NPI:1194299487
Name:BILLUPS BUCKNER, DAPHNE
Entity type:Individual
Prefix:DR
First Name:DAPHNE
Middle Name:
Last Name:BILLUPS BUCKNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8119 S CHRISTIANA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60652-2513
Mailing Address - Country:US
Mailing Address - Phone:773-412-6098
Mailing Address - Fax:
Practice Address - Street 1:8119 S CHRISTIANA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60652-2513
Practice Address - Country:US
Practice Address - Phone:773-412-6098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-19
Last Update Date:2019-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051288569183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist