Provider Demographics
NPI:1578844718
Name:HICKS, JENNIFER M (PHARMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:HICKS
Suffix:
Gender:F
Credentials:PHARMD
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 762
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-0762
Mailing Address - Country:US
Mailing Address - Phone:912-660-9976
Mailing Address - Fax:
Practice Address - Street 1:1711 N MORLEY ST
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-3630
Practice Address - Country:US
Practice Address - Phone:660-263-0793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011007381183500000X
GARPH025063183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist