Provider Demographics
NPI:1922368240
Name:DICKENSON PHARMACY PC
Entity Type:Organization
Organization Name:DICKENSON PHARMACY PC
Other - Org Name:DICKENSON DRUG COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-617-8144
Mailing Address - Street 1:PO BOX 215
Mailing Address - Street 2:
Mailing Address - City:RURAL RETREAT
Mailing Address - State:VA
Mailing Address - Zip Code:24368-0215
Mailing Address - Country:US
Mailing Address - Phone:276-686-5073
Mailing Address - Fax:
Practice Address - Street 1:580 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RURAL RETREAT
Practice Address - State:VA
Practice Address - Zip Code:24368-2564
Practice Address - Country:US
Practice Address - Phone:276-686-5073
Practice Address - Fax:276-686-5074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-21
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010044683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1922368240Medicaid
2135292OtherPK