Provider Demographics
NPI:1730473075
Name:DICKERSON, RILEY CLARK (DPH)
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:CLARK
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5604 HIXSON PIKE
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-3243
Mailing Address - Country:US
Mailing Address - Phone:423-842-3500
Mailing Address - Fax:423-842-7483
Practice Address - Street 1:5604 HIXSON PIKE
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-3243
Practice Address - Country:US
Practice Address - Phone:423-842-3500
Practice Address - Fax:423-842-7483
Is Sole Proprietor?:No
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNC3676183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist