MEDICARE: DANA 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	051-039328	IL

General Provider Information

NPI Number	:	1881977668
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANA DICKSON RPH

Provider Business Mailing Address
First Line	:	112 N HAMILTON DR
Second Line	:	BOX 5
City	:	GRANT PARK
State	:	IL
Zip	:	60940-7257
Country	:	US
Telephone Number	:	815-937-0528
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 N HAMILTON DR
Second Line	:	BOX 5
City	:	GRANT PARK
State	:	IL
Zip	:	60940-7257
Country	:	US
Telephone Number	:	815-937-0528
Fax Number	:

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

Provider Enumeration Date	:	09/27/2011
Last Update Date	:	09/27/2011

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