Provider Demographics
NPI:1295840239
Name:THE DICKSON APOTHECARY LLC
Entity Type:Organization
Organization Name:THE DICKSON APOTHECARY LLC
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:570-296-5138
Mailing Address - Street 1:105 WHEATFIELD DR
Mailing Address - Street 2:SUITE 2 PRIME TIME PLAZA
Mailing Address - City:MILFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18337-7809
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 WHEATFIELD DR
Practice Address - Street 2:SUITE 2 PRIME TIME PLAZA
Practice Address - City:MILFORD
Practice Address - State:PA
Practice Address - Zip Code:18337
Practice Address - Country:US
Practice Address - Phone:570-296-5138
Practice Address - Fax:570-296-5386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP481527333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3985376OtherOTHER ID NUMBER-COMMERCIAL NUMBER
PA1014838170001Medicaid
PABT9581895OtherDEA #
3985376OtherOTHER ID NUMBER-COMMERCIAL NUMBER