Provider Demographics
NPI:1093757619
Name:HICKMANS PRESCRIPTION DRUGGIST INC
Entity Type:Organization
Organization Name:HICKMANS PRESCRIPTION DRUGGIST INC
Other - Org Name:HICKMANS EAST PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-425-1077
Mailing Address - Street 1:306 ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-3600
Mailing Address - Country:US
Mailing Address - Phone:304-425-1077
Mailing Address - Fax:304-425-4250
Practice Address - Street 1:306 ROGERS ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-3600
Practice Address - Country:US
Practice Address - Phone:304-425-1077
Practice Address - Fax:304-425-4250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVSP05523093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0141947001Medicaid
2109475OtherPK
1104080002Medicare NSC