Provider Demographics
NPI:1235738295
Name:DICKERSON, LORI (RPH)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:DICKERSON
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 1:300 KROGER CTR
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-8895
Mailing Address - Country:US
Mailing Address - Phone:606-783-1476
Mailing Address - Fax:606-780-9484
Practice Address - Street 1:300 KROGER CTR
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-8895
Practice Address - Country:US
Practice Address - Phone:606-783-1476
Practice Address - Fax:606-780-9484
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY010475183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist