Provider Demographics
NPI:1073779260
Name:HICKS, MICHAEL SUTTLES (RPH DHPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SUTTLES
Last Name:HICKS
Suffix:
Gender:M
Credentials:RPH DHPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1858
Mailing Address - Country:US
Mailing Address - Phone:229-242-3060
Mailing Address - Fax:229-242-9914
Practice Address - Street 1:212 NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1858
Practice Address - Country:US
Practice Address - Phone:229-242-3060
Practice Address - Fax:229-242-9914
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-06
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016110183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist