Provider Demographics
NPI:1306122783
Name:DICKS, DAVID KENNETH (BS)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:KENNETH
Last Name:DICKS
Suffix:
Gender:M
Credentials:BS
Other - Prefix:MR
Other - First Name:DAVID
Other - Middle Name:KENNETH
Other - Last Name:DICKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BS
Mailing Address - Street 1:3040 N SOUTHERN HILLS DR
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60083-9292
Mailing Address - Country:US
Mailing Address - Phone:847-530-5268
Mailing Address - Fax:
Practice Address - Street 1:3805 80TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-4951
Practice Address - Country:US
Practice Address - Phone:262-694-0750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-28
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12612-40183500000X
IL051-034873183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist