Provider Demographics
NPI:1467555094
Name:HICKS, DEREK VERLDON (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:VERLDON
Last Name:HICKS
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 297
Mailing Address - Street 2:
Mailing Address - City:NEW TAZEWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37824-0297
Mailing Address - Country:US
Mailing Address - Phone:423-626-5411
Mailing Address - Fax:423-626-6538
Practice Address - Street 1:606 N BROAD STREET
Practice Address - Street 2:
Practice Address - City:NEW TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37825-6610
Practice Address - Country:US
Practice Address - Phone:423-626-5411
Practice Address - Fax:423-626-6538
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8336183500000X
GA016861183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist