Provider Demographics
NPI:1932361896
Name:HICKS, SUSAN VANDERWERF (RPH)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:VANDERWERF
Last Name:HICKS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 AUDUBON DR
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-4594
Mailing Address - Country:US
Mailing Address - Phone:850-267-6767
Mailing Address - Fax:
Practice Address - Street 1:400 AUDUBON DR
Practice Address - Street 2:
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-4594
Practice Address - Country:US
Practice Address - Phone:850-267-6767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-01
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS19596183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist