Provider Demographics
NPI:1861672784
Name:DEDRICK, ALICE JESSUP (RPH)
Entity Type:Individual
Prefix:MS
First Name:ALICE
Middle Name:JESSUP
Last Name:DEDRICK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 TUNBRIDGE WALKE
Mailing Address - Street 2:
Mailing Address - City:EAST AURORA
Mailing Address - State:NY
Mailing Address - Zip Code:14052-2019
Mailing Address - Country:US
Mailing Address - Phone:716-652-1492
Mailing Address - Fax:
Practice Address - Street 1:4900 BROADWAY
Practice Address - Street 2:
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-3934
Practice Address - Country:US
Practice Address - Phone:716-681-4255
Practice Address - Fax:716-681-7598
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026482183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00482751Medicaid