Provider Demographics
NPI:1295441384
Name:DIXON, KRISTEN TIERRA
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:TIERRA
Last Name:DIXON
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 1:459 LOLLIE DR
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-8701
Mailing Address - Country:US
Mailing Address - Phone:478-279-2581
Mailing Address - Fax:
Practice Address - Street 1:400 BRYANT AVE
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-3813
Practice Address - Country:US
Practice Address - Phone:501-847-4615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD16307183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist