Provider Demographics
NPI:1104146596
Name:DICKERSON, KENT FRANCES (RPH)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:FRANCES
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2036 LAKE MICHIGAN DR NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-4743
Mailing Address - Country:US
Mailing Address - Phone:616-453-8750
Mailing Address - Fax:616-453-0107
Practice Address - Street 1:2036 LAKE MICHIGAN DR NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-4743
Practice Address - Country:US
Practice Address - Phone:616-453-8750
Practice Address - Fax:616-453-0107
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302031457183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist