Provider Demographics
NPI:1467716670
Name:HICKS, BRANDON L (PHARM D)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:L
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 1:1252 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:ERWIN
Mailing Address - State:TN
Mailing Address - Zip Code:37650-9122
Mailing Address - Country:US
Mailing Address - Phone:423-743-5271
Mailing Address - Fax:
Practice Address - Street 1:1252 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:ERWIN
Practice Address - State:TN
Practice Address - Zip Code:37650-9122
Practice Address - Country:US
Practice Address - Phone:423-571-2649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000036744183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist