Healthcare Provider Details

I. General information

NPI: 1669093738
Provider Name (Legal Business Name): JESSICA MARIE DYSON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2020
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 S BROADWAY
PERU IN
46970-2232
US

IV. Provider business mailing address

1147 E 900 S
LA FONTAINE IN
46940-8900
US

V. Phone/Fax

Practice location:
  • Phone: 765-472-4367
  • Fax:
Mailing address:
  • Phone: 260-571-3456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26025591A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: