Provider Demographics
NPI:1134721244
Name:DICKSON, SUE ELLEN (RPH)
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:ELLEN
Last Name:DICKSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 JACOB LN
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-3481
Mailing Address - Country:US
Mailing Address - Phone:636-937-9717
Mailing Address - Fax:
Practice Address - Street 1:12862 STATE ROUTE 21
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:MO
Practice Address - Zip Code:63020-1096
Practice Address - Country:US
Practice Address - Phone:636-586-9666
Practice Address - Fax:636-586-7700
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044326183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist