Provider Demographics
NPI:1821406414
Name:HICKMAN, LISA (PHARM D)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HICKMAN
Suffix:
Gender:F
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 1:12900 W THUNDERBIRD RD
Mailing Address - Street 2:
Mailing Address - City:EL MIRAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:85335-5945
Mailing Address - Country:US
Mailing Address - Phone:623-583-8725
Mailing Address - Fax:623-583-8775
Practice Address - Street 1:12900 W THUNDERBIRD RD
Practice Address - Street 2:
Practice Address - City:EL MIRAGE
Practice Address - State:AZ
Practice Address - Zip Code:85335-5945
Practice Address - Country:US
Practice Address - Phone:623-583-8725
Practice Address - Fax:623-583-8775
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-26
Last Update Date:2014-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS014944183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS014944OtherPHARMACIST LICENSE NUMBER