Provider Demographics
NPI:1447063276
Name:DICKERSON, RICHANQUA J
Entity type:Individual
Prefix:
First Name:RICHANQUA
Middle Name:J
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 W SUNCREST LOOP
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-1674
Mailing Address - Country:US
Mailing Address - Phone:504-756-0196
Mailing Address - Fax:
Practice Address - Street 1:17122 AIRLINE HWY
Practice Address - Street 2:
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-3402
Practice Address - Country:US
Practice Address - Phone:225-673-9971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.025614183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist