Provider Demographics
NPI:1518223056
Name:HICKS, JERRY L SR (RPH)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:L
Last Name:HICKS
Suffix:SR
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 1:10201 SE 240TH ST
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-4895
Mailing Address - Country:US
Mailing Address - Phone:253-859-5533
Mailing Address - Fax:253-859-5541
Practice Address - Street 1:10201 SE 240TH ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98031-4895
Practice Address - Country:US
Practice Address - Phone:253-859-5533
Practice Address - Fax:253-859-5541
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00009801183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist