Provider Demographics
NPI:1710568837
Name:DICKERSON, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:DICKERSON
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 1:1401 3RD AVE N APT 101
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37208-3269
Mailing Address - Country:US
Mailing Address - Phone:770-778-0909
Mailing Address - Fax:
Practice Address - Street 1:104 TN-52 W
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148
Practice Address - Country:US
Practice Address - Phone:615-325-4058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN42646183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist