Provider Demographics
NPI:1952917817
Name:DICKINSON PHARMACY LLC
Entity Type:Organization
Organization Name:DICKINSON PHARMACY LLC
Other - Org Name:DICKINSON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:DE LA VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-769-0153
Mailing Address - Street 1:3717 HIGHWAY 3 STE D
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:TX
Mailing Address - Zip Code:77539-8024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3717 HIGHWAY 3 STE D
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:TX
Practice Address - Zip Code:77539-8024
Practice Address - Country:US
Practice Address - Phone:832-769-0153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-16
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy