Provider Demographics
NPI:1447550793
Name:DICKSON, REX GWYNN (RPH)
Entity type:Individual
Prefix:
First Name:REX
Middle Name:GWYNN
Last Name:DICKSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 EAST MERIDIAN
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WA
Mailing Address - Zip Code:98354
Mailing Address - Country:US
Mailing Address - Phone:253-952-0390
Mailing Address - Fax:253-952-4354
Practice Address - Street 1:900 MERIDIAN E
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:WA
Practice Address - Zip Code:98354-7001
Practice Address - Country:US
Practice Address - Phone:253-952-0390
Practice Address - Fax:253-952-4354
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 00010966183500000X
AK1501183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist