Provider Demographics
NPI:1063005270
Name:DICKERSON, MISTY LOWERY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MISTY
Middle Name:LOWERY
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1439 JESSE JEWELL PKWY NE STE 101
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3806
Mailing Address - Country:US
Mailing Address - Phone:770-219-6337
Mailing Address - Fax:770-219-6338
Practice Address - Street 1:1439 JESSE JEWELL PKWY NE STE 101
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3806
Practice Address - Country:US
Practice Address - Phone:770-219-6337
Practice Address - Fax:770-219-6338
Is Sole Proprietor?:No
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023724183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH023724OtherGEORGIA STATE BOARD OF PHARMACY