Provider Demographics
NPI:1316639925
Name:NGUEKENG, REINE ANITA MAGNIFO
Entity type:Individual
Prefix:
First Name:REINE ANITA
Middle Name:MAGNIFO
Last Name:NGUEKENG
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 1:210 CIRCLE AVE APT 503
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-1366
Mailing Address - Country:US
Mailing Address - Phone:312-459-2796
Mailing Address - Fax:
Practice Address - Street 1:1601 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3144
Practice Address - Country:US
Practice Address - Phone:630-653-6940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051305500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist