Healthcare Provider Details

I. General information

NPI: 1104146596
Provider Name (Legal Business Name): KENT FRANCES DICKERSON RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 06/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2036 LAKE MICHIGAN DR NW
GRAND RAPIDS MI
49504-4743
US

IV. Provider business mailing address

2036 LAKE MICHIGAN DR NW
GRAND RAPIDS MI
49504-4743
US

V. Phone/Fax

Practice location:
  • Phone: 616-453-8750
  • Fax: 616-453-0107
Mailing address:
  • Phone: 616-453-8750
  • Fax: 616-453-0107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302031457
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: