Provider Demographics
NPI:1043206493
Name:COLUMBIA HICKORY PHARMACY INC
Entity Type:Organization
Organization Name:COLUMBIA HICKORY PHARMACY INC
Other - Org Name:COLUMBIA HICKORY CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HYUNG
Authorized Official - Middle Name:J
Authorized Official - Last Name:NA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-964-6409
Mailing Address - Street 1:10805 HICKORY RIDGE RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-3626
Mailing Address - Country:US
Mailing Address - Phone:410-964-6409
Mailing Address - Fax:410-964-6493
Practice Address - Street 1:10805 HICKORY RIDGE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3626
Practice Address - Country:US
Practice Address - Phone:410-964-6409
Practice Address - Fax:410-964-6493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MDP041903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD407608700Medicaid
2037991OtherPK
MD407608700Medicaid