Provider Demographics
NPI:1568643617
Name:DICKSON, AMY JANE (RPH)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:JANE
Last Name:DICKSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:JANE
Other - Last Name:PANEPINTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17 GRAND COVE WAY
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020-7222
Mailing Address - Country:US
Mailing Address - Phone:201-927-6076
Mailing Address - Fax:
Practice Address - Street 1:50 SPRING VALLEY MARKETPLACE
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10977-5213
Practice Address - Country:US
Practice Address - Phone:845-371-5811
Practice Address - Fax:845-371-5811
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRI24909183500000X
NY047178183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02243552Medicaid