Provider Demographics
NPI:1700177938
Name:DICKEY, SHANNON G (RPH)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:G
Last Name:DICKEY
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 1:4010 BREEZY HILL LN
Mailing Address - Street 2:4010 BREEZY HILL LN
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-8510
Mailing Address - Country:US
Mailing Address - Phone:228-327-5254
Mailing Address - Fax:
Practice Address - Street 1:3082 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-4354
Practice Address - Country:US
Practice Address - Phone:228-872-2646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD-7399183500000X
AL13436183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist