Provider Demographics
NPI:1801408380
Name:SIMMS, TARA HICKEY
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:HICKEY
Last Name:SIMMS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:TARA
Other - Middle Name:DEE
Other - Last Name:HICKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:4406 JOHNSTON ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-4234
Mailing Address - Country:US
Mailing Address - Phone:337-984-5220
Mailing Address - Fax:
Practice Address - Street 1:4406 JOHNSTON ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-4234
Practice Address - Country:US
Practice Address - Phone:337-984-5220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016313183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist