Provider Demographics
NPI:1588183974
Name:HICKLEN, SHANICE
Entity Type:Individual
Prefix:
First Name:SHANICE
Middle Name:
Last Name:HICKLEN
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 1:17136 WESTMILL LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-3171
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4875 OLD YORK RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-8127
Practice Address - Country:US
Practice Address - Phone:803-323-2080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-17
Last Update Date:2017-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37232183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist