Basic Information
| Provider Information | |||||||||
| NPI: | 1134325558 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EUBANKS | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | FAYE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | POWELL | ||||||||
| OtherFirstName: | ALICIA | ||||||||
| OtherMiddleName: | FAYE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 155 | ||||||||
| Address2: | REA CLINIC | ||||||||
| City: | CHRISTOPHER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6187242401 | ||||||||
| FaxNumber: | 6187242571 | ||||||||
| Practice Location | |||||||||
| Address1: | 4241 STATE HIGHWAY 14 WEST | ||||||||
| Address2: | REA CLINIC PHARMACY | ||||||||
| City: | CHRISTOPHER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6187242136 | ||||||||
| FaxNumber: | 6187244628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183700000X | IL | Y | Pharmacy Service Providers | Pharmacy Technician |
No ID Information.