Provider Demographics
NPI:1073508289
Name:DICKERSON, JAMES G SR
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:G
Last Name:DICKERSON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15001 S HIGHWAY 31
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:NE
Mailing Address - Zip Code:68028-6312
Mailing Address - Country:US
Mailing Address - Phone:402-672-4636
Mailing Address - Fax:402-449-4531
Practice Address - Street 1:601 N 30TH ST
Practice Address - Street 2:SUITE 2807
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-2137
Practice Address - Country:US
Practice Address - Phone:402-449-4560
Practice Address - Fax:402-449-4531
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7632183500000X
IA12903183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist