Provider Demographics
NPI:1700394210
Name:HICKS, YANICK
Entity Type:Individual
Prefix:
First Name:YANICK
Middle Name:
Last Name:HICKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4032 W OSBORN RD APT 203
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85019-3970
Mailing Address - Country:US
Mailing Address - Phone:510-209-9951
Mailing Address - Fax:
Practice Address - Street 1:23477 W YUMA RD
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-3103
Practice Address - Country:US
Practice Address - Phone:623-337-9161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS023119183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist