Provider Demographics
NPI:1174417661
Name:FAULKNER, RAVYN
Entity type:Individual
Prefix:
First Name:RAVYN
Middle Name:
Last Name:FAULKNER
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 1:3654 S PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-1009
Mailing Address - Country:US
Mailing Address - Phone:312-810-1912
Mailing Address - Fax:
Practice Address - Street 1:21000 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1935
Practice Address - Country:US
Practice Address - Phone:708-898-9114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-07
Last Update Date:2025-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051306866183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist