Provider Demographics
NPI:1356439558
Name:HICKSVILLE PHARMACY & HOME MEDICAL INC
Entity Type:Organization
Organization Name:HICKSVILLE PHARMACY & HOME MEDICAL INC
Other - Org Name:HICKSVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHON
Authorized Official - Middle Name:M
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-542-6218
Mailing Address - Street 1:116 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43526-1107
Mailing Address - Country:US
Mailing Address - Phone:419-542-6218
Mailing Address - Fax:419-542-8246
Practice Address - Street 1:116 E HIGH ST
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43526-1107
Practice Address - Country:US
Practice Address - Phone:419-542-6218
Practice Address - Fax:419-542-8246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
OH0220910503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3613076OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OH3090560Medicaid
6485910001Medicare NSC