Provider Demographics
NPI:1295162048
Name:DICKERSON, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 HIGHWAY 28 BY-PASS
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29625
Mailing Address - Country:US
Mailing Address - Phone:864-224-7469
Mailing Address - Fax:864-716-0406
Practice Address - Street 1:922 HIGHWAY 28 BY-PASS
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29625
Practice Address - Country:US
Practice Address - Phone:864-224-7469
Practice Address - Fax:864-716-0406
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-10
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8002183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist