Healthcare Provider Details

I. General information

NPI: 1134400724
Provider Name (Legal Business Name): CHRISTINE KATHERINE LICINA PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2011
Last Update Date: 04/25/2026
Certification Date: 04/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1704 W DEYOUNG ST
MARION IL
62959-1054
US

IV. Provider business mailing address

202 CARLISLE CT
OSWEGO IL
60543-7531
US

V. Phone/Fax

Practice location:
  • Phone: 618-993-6330
  • Fax:
Mailing address:
  • Phone: 630-551-4157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051-039350
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: