Provider Demographics
NPI:1043588205
Name:DIXON, TIAJUANA
Entity Type:Individual
Prefix:
First Name:TIAJUANA
Middle Name:
Last Name:DIXON
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 1:12854 ASHLAND
Mailing Address - Street 2:
Mailing Address - City:CALUMET PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12854 S ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CALUMET PARK
Practice Address - State:IL
Practice Address - Zip Code:60827-6308
Practice Address - Country:US
Practice Address - Phone:708-239-1136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.287455183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist