MEDICARE: TIAJUANA DIXON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	051.287455	IL

General Provider Information

NPI Number	:	1043588205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIAJUANA DIXON

Provider Business Mailing Address
First Line	:	12854 ASHLAND
Second Line	:
City	:	CALUMET PARK
State	:	IL
Zip	:	60408
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12854 S ASHLAND AVE
Second Line	:
City	:	CALUMET PARK
State	:	IL
Zip	:	60827-6308
Country	:	US
Telephone Number	:	708-239-1136
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2011
Last Update Date	:	12/02/2011

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Directions to “ TIAJUANA DIXON ” Practice Location

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