Provider Demographics
NPI:1407108640
Name:DICKENS, ANDREA STACY (PHARMD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:STACY
Last Name:DICKENS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 BRAESWOOD PARK DR
Mailing Address - Street 2:APT 336
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-4454
Mailing Address - Country:US
Mailing Address - Phone:509-338-5024
Mailing Address - Fax:
Practice Address - Street 1:2255 BRAESWOOD PARK DR
Practice Address - Street 2:APT 336
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4454
Practice Address - Country:US
Practice Address - Phone:509-338-5024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-12
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 60215918183500000X
TX537861835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835X0200XPharmacy Service ProvidersPharmacistOncology
No183500000XPharmacy Service ProvidersPharmacist