Provider Demographics
NPI:1427407857
Name:DICKERSON, DUSTIN (PHARMD)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 FOUR STAR DR E
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:OH
Mailing Address - Zip Code:43119-8441
Mailing Address - Country:US
Mailing Address - Phone:614-315-0175
Mailing Address - Fax:
Practice Address - Street 1:1404 FOUR STAR DR E
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:OH
Practice Address - Zip Code:43119-8441
Practice Address - Country:US
Practice Address - Phone:614-315-0175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03326656183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist