Provider Demographics
NPI:1912359613
Name:DICKERSON, TYLER (PHARMD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1955 DEER RUN LN
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:OH
Mailing Address - Zip Code:43140-8986
Mailing Address - Country:US
Mailing Address - Phone:614-738-8370
Mailing Address - Fax:
Practice Address - Street 1:3200 VINE ST
Practice Address - Street 2:PHARMACY (119)
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-2213
Practice Address - Country:US
Practice Address - Phone:513-861-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03135692183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist