Provider Demographics
NPI:1578230314
Name:HICKS, SHELBY TAYLOR
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:TAYLOR
Last Name:HICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 W RIVER RD APT 7205
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-1711
Mailing Address - Country:US
Mailing Address - Phone:916-307-3672
Mailing Address - Fax:
Practice Address - Street 1:615 N ALVERNON WAY
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-1900
Practice Address - Country:US
Practice Address - Phone:520-320-1194
Practice Address - Fax:520-320-3792
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-29
Last Update Date:2021-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS025061183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist