Provider Demographics
NPI:1235568106
Name:DICKEY, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:DICKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16151 19 MILE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1157
Mailing Address - Country:US
Mailing Address - Phone:586-263-2677
Mailing Address - Fax:586-263-2591
Practice Address - Street 1:16151 19 MILE RD STE 100
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1157
Practice Address - Country:US
Practice Address - Phone:586-263-2677
Practice Address - Fax:586-263-2591
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027178183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist