Provider Demographics
NPI:1053681569
Name:DIXON, CEIL D
Entity Type:Individual
Prefix:
First Name:CEIL
Middle Name:D
Last Name:DIXON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CEIL
Other - Middle Name:D
Other - Last Name:DIXON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BS PHARMACY
Mailing Address - Street 1:977 ELLIS AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-6256
Mailing Address - Country:US
Mailing Address - Phone:601-944-9965
Mailing Address - Fax:601-709-7875
Practice Address - Street 1:977 ELLIS AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-6256
Practice Address - Country:US
Practice Address - Phone:601-944-9965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-01
Last Update Date:2012-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1320432183500000X
MS07873183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1320432Medicaid