MEDICARE: DR. KIMBERLY MCLEAN HICKS PHARM.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	1835P0018X	FL

General Provider Information

NPI Number	:	1093069189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIMBERLY MCLEAN HICKS PHARM.D

Provider Business Mailing Address
First Line	:	376 S NORTH LAKE BLVD
Second Line	:	SUITE 1008
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32701-5261
Country	:	US
Telephone Number	:	800-628-6965
Fax Number	:	180-026-9549

Provider Business Practice Location Address
First Line	:	376 S NORTH LAKE BLVD
Second Line	:	SUITE 1008
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32701-5261
Country	:	US
Telephone Number	:	800-628-6965
Fax Number	:	180-026-9549

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/29/2012
Last Update Date	:	10/29/2012

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