Provider Demographics
NPI:1528656915
Name:KUSPER, DOMINIKA
Entity type:Individual
Prefix:DR
First Name:DOMINIKA
Middle Name:
Last Name:KUSPER
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 1:12471 SPYGLASS CT
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-8117
Mailing Address - Country:US
Mailing Address - Phone:773-653-0999
Mailing Address - Fax:
Practice Address - Street 1:1 MAIN ST
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-2366
Practice Address - Country:US
Practice Address - Phone:708-747-5562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-01
Last Update Date:2021-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.299017183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist