Provider Demographics
NPI:1174616494
Name:HICKMAN, JOHN ROGER III (RPH)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ROGER
Last Name:HICKMAN
Suffix:III
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 12TH STREET EXT
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2352
Mailing Address - Country:US
Mailing Address - Phone:304-425-2188
Mailing Address - Fax:304-425-2189
Practice Address - Street 1:199 12TH STREET EXT
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2352
Practice Address - Country:US
Practice Address - Phone:304-425-2188
Practice Address - Fax:304-425-2189
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV5286183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVNABPOther50033778