MEDICARE: JOHN KENT DICKSON RPH

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	114900-9	MN

General Provider Information

NPI Number	:	1417178062
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN KENT DICKSON RPH

Provider Business Mailing Address
First Line	:	4895 BASSETT CREEK DR
Second Line	:
City	:	GOLDEN VALLEY
State	:	MN
Zip	:	55422-4169
Country	:	US
Telephone Number	:	763-588-9933
Fax Number	:

Provider Business Practice Location Address
First Line	:	4895 BASSETT CREEK DR
Second Line	:
City	:	GOLDEN VALLEY
State	:	MN
Zip	:	55422-4169
Country	:	US
Telephone Number	:	763-588-9933
Fax Number	:

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

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	07/08/2007

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