Provider Demographics
NPI:1982208245
Name:DICKERSON, AMY (PHARMD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47620-2011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 E 4TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IN
Practice Address - Zip Code:47620-2011
Practice Address - Country:US
Practice Address - Phone:812-838-5089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26027984A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist