Provider Demographics
NPI:1760087209
Name:HICKMAN, ROBERTA
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:HICKMAN
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 1:238 CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-2728
Mailing Address - Country:US
Mailing Address - Phone:267-246-6025
Mailing Address - Fax:
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5189
Practice Address - Country:US
Practice Address - Phone:215-707-4643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP039375L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist