Provider Demographics
NPI:1821193129
Name:DIXON, JERRY WAYNE (RPH)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:WAYNE
Last Name:DIXON
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 1:174 PERRY HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750-8838
Mailing Address - Country:US
Mailing Address - Phone:229-423-2313
Mailing Address - Fax:
Practice Address - Street 1:174 PERRY HOUSE RD
Practice Address - Street 2:
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750-8838
Practice Address - Country:US
Practice Address - Phone:229-423-2313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10075183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1109897Medicare UPIN