MEDICARE: ANDREA STACY DICKENS PHARMD

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	PH 60215918	WA
2	1835X0200X	Oncology Pharmacist	53786	TX

General Provider Information

NPI Number	:	1407108640
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA STACY DICKENS PHARMD

Provider Business Mailing Address
First Line	:	2255 BRAESWOOD PARK DR
Second Line	:	APT 336
City	:	HOUSTON
State	:	TX
Zip	:	77030-4454
Country	:	US
Telephone Number	:	509-338-5024
Fax Number	:

Provider Business Practice Location Address
First Line	:	2255 BRAESWOOD PARK DR
Second Line	:	APT 336
City	:	HOUSTON
State	:	TX
Zip	:	77030-4454
Country	:	US
Telephone Number	:	509-338-5024
Fax Number	:

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

Provider Enumeration Date	:	10/12/2012
Last Update Date	:	10/04/2013

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