Provider Demographics
NPI:1609145879
Name:HICKS, JASON A (PHARM D)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:A
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 1:1703 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-3193
Mailing Address - Country:US
Mailing Address - Phone:615-444-3576
Mailing Address - Fax:615-444-6374
Practice Address - Street 1:1703 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-3193
Practice Address - Country:US
Practice Address - Phone:615-444-3576
Practice Address - Fax:615-444-6374
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-17
Last Update Date:2011-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11683183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist