Provider Demographics
NPI:1972642205
Name:DEWEESE, RICKY GENE (RPH)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:GENE
Last Name:DEWEESE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:RICKY
Other - Middle Name:GENE
Other - Last Name:DEWEESE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:1001 HOLLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-2161
Mailing Address - Country:US
Mailing Address - Phone:601-781-2310
Mailing Address - Fax:601-781-2310
Practice Address - Street 1:12491 ROAD 614
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-5668
Practice Address - Country:US
Practice Address - Phone:601-389-6567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE 6068183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist