Provider Demographics
NPI:1336620285
Name:DIXON, KEN R (RPH)
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:R
Last Name:DIXON
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 1:6105 PEACE SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LOOMIS
Mailing Address - State:CA
Mailing Address - Zip Code:95650-9155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6105 PEACE SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LOOMIS
Practice Address - State:CA
Practice Address - Zip Code:95650-9155
Practice Address - Country:US
Practice Address - Phone:916-824-4839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42455183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist