Provider Demographics
NPI:1457755993
Name:DICKEY, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DICKEY
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 1:11233 DUMETZ LN
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-6578
Mailing Address - Country:US
Mailing Address - Phone:909-575-8381
Mailing Address - Fax:
Practice Address - Street 1:1180 N STATE ST
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-6318
Practice Address - Country:US
Practice Address - Phone:951-487-1915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71658183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist