Provider Demographics
NPI:1164761573
Name:DICKSON, KELLY ANN (RPH)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:DICKSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 WHEATFIELD DR
Mailing Address - Street 2:SUITE #2
Mailing Address - City:MILFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18337-7809
Mailing Address - Country:US
Mailing Address - Phone:570-296-5138
Mailing Address - Fax:570-296-5386
Practice Address - Street 1:105 WHEATFIELD DR
Practice Address - Street 2:SUITE #2
Practice Address - City:MILFORD
Practice Address - State:PA
Practice Address - Zip Code:18337-7809
Practice Address - Country:US
Practice Address - Phone:570-296-5138
Practice Address - Fax:570-296-5386
Is Sole Proprietor?:No
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP040138L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101483817801Medicaid