Provider Demographics
NPI:1669057246
Name:PICKARD, DALE CARLYLE
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:CARLYLE
Last Name:PICKARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DALE
Other - Middle Name:CARLYLE
Other - Last Name:PICKARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PD
Mailing Address - Street 1:4102 MAGEE DR
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-8410
Mailing Address - Country:US
Mailing Address - Phone:903-824-8129
Mailing Address - Fax:
Practice Address - Street 1:1201 E 35TH ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-2746
Practice Address - Country:US
Practice Address - Phone:870-774-3666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD08680183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist