Provider Demographics
NPI:1699045625
Name:DICKERSON, EDWARD (RPH)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33948
Mailing Address - Country:US
Mailing Address - Phone:941-625-4847
Mailing Address - Fax:914-625-8197
Practice Address - Street 1:1800 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948
Practice Address - Country:US
Practice Address - Phone:941-625-4847
Practice Address - Fax:914-625-8197
Is Sole Proprietor?:No
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS39302183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist