Provider Demographics
NPI:1831254143
Name:DICKERSON, ROBERT PAUL
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:PAUL
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5080 LAKE PIERCE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33898-8884
Mailing Address - Country:US
Mailing Address - Phone:863-439-3506
Mailing Address - Fax:863-439-3506
Practice Address - Street 1:1009 N CHURCH AVE
Practice Address - Street 2:
Practice Address - City:MULBERRY
Practice Address - State:FL
Practice Address - Zip Code:33860-2039
Practice Address - Country:US
Practice Address - Phone:863-425-1101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS15066183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist