Provider Demographics
NPI:1225171416
Name:DICKERSON, JOHN BRETT
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:BRETT
Last Name:DICKERSON
Suffix:
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:RT 3 BOX 970
Mailing Address - Street 2:
Mailing Address - City:OLIVE HILL
Mailing Address - State:KY
Mailing Address - Zip Code:41164
Mailing Address - Country:US
Mailing Address - Phone:606-738-9790
Mailing Address - Fax:606-738-4030
Practice Address - Street 1:100 HUNTER STREET
Practice Address - Street 2:
Practice Address - City:SANDY HOOK
Practice Address - State:KY
Practice Address - Zip Code:41171
Practice Address - Country:US
Practice Address - Phone:606-738-4041
Practice Address - Fax:606-738-4030
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY011442183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist