Provider Demographics
NPI:1407070170
Name:DICKASON, PETER
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:DICKASON
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 1:933 HELENE CT
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-1460
Mailing Address - Country:US
Mailing Address - Phone:707-584-7651
Mailing Address - Fax:707-544-6147
Practice Address - Street 1:1551 FARMERS LN
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7525
Practice Address - Country:US
Practice Address - Phone:707-544-4050
Practice Address - Fax:707-544-6147
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57021183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist