Provider Demographics
NPI:1669756417
Name:DICKERSON, JARED SAMUEL (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JARED
Middle Name:SAMUEL
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 PARKDALE DR
Mailing Address - Street 2:APT 15D
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-4910
Mailing Address - Country:US
Mailing Address - Phone:864-353-3943
Mailing Address - Fax:
Practice Address - Street 1:3725 RIVERS AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-7038
Practice Address - Country:US
Practice Address - Phone:843-745-8655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13529183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist