Provider Demographics
NPI:1851608061
Name:HICKS, MATTHEW L (PHARMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:L
Last Name:HICKS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 ROSE LN
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NY
Mailing Address - Zip Code:13323-3729
Mailing Address - Country:US
Mailing Address - Phone:607-743-8691
Mailing Address - Fax:
Practice Address - Street 1:49 KELLOGG RD
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-2849
Practice Address - Country:US
Practice Address - Phone:315-734-1893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY02055079183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist