Provider Demographics
NPI:1740284298
Name:HICKS PHARMACY LLC
Entity type:Organization
Organization Name:HICKS PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:OLIVER
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:336-591-4345
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:WALNUT COVE
Mailing Address - State:NC
Mailing Address - Zip Code:27052-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1072 N MAIN ST
Practice Address - Street 2:STE 103
Practice Address - City:WALNUT COVE
Practice Address - State:NC
Practice Address - Zip Code:27052-9312
Practice Address - Country:US
Practice Address - Phone:336-591-4345
Practice Address - Fax:336-591-3435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2095332B00000X
332B00000X, 333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0855023Medicaid
NC7701174Medicaid
3411890OtherOTHER ID NUMBER
NC7701174Medicaid