Provider Demographics
NPI:1508469321
Name:DICKSON, MICHAEL LEE
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEE
Last Name:DICKSON
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 1:142 TALCOTTVILLE RD
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4705
Mailing Address - Country:US
Mailing Address - Phone:860-871-1661
Mailing Address - Fax:
Practice Address - Street 1:142 TALCOTTVILLE RD
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4705
Practice Address - Country:US
Practice Address - Phone:860-871-1661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT08361183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist