Provider Demographics
NPI:1871185256
Name:DICKENS, STACY MICHAEL
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:MICHAEL
Last Name:DICKENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 CAPITAL AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-1832
Mailing Address - Country:US
Mailing Address - Phone:706-769-1275
Mailing Address - Fax:706-769-3216
Practice Address - Street 1:1160 CAPITAL AVE STE 101
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-1832
Practice Address - Country:US
Practice Address - Phone:706-769-1275
Practice Address - Fax:706-769-3216
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH017237183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist