Healthcare Provider Details

I. General information

NPI: 1164791323
Provider Name (Legal Business Name): SADIE ELIZABETH DYKSTRA PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2011
Last Update Date: 12/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 VILLAGE GREEN PL
CHAMPAIGN IL
61822-7681
US

IV. Provider business mailing address

609 E BURKWOOD CT
URBANA IL
61801-5907
US

V. Phone/Fax

Practice location:
  • Phone: 217-398-2764
  • Fax:
Mailing address:
  • Phone: 217-369-3690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051-288394
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: