MEDICARE: JASON A 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	183500000X	Pharmacist	11683	TN

General Provider Information

NPI Number	:	1609145879
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON A HICKS PHARM D

Provider Business Mailing Address
First Line	:	1703 W MAIN ST
Second Line	:
City	:	LEBANON
State	:	TN
Zip	:	37087-3193
Country	:	US
Telephone Number	:	615-444-3576
Fax Number	:	615-444-6374

Provider Business Practice Location Address
First Line	:	1703 W MAIN ST
Second Line	:
City	:	LEBANON
State	:	TN
Zip	:	37087-3193
Country	:	US
Telephone Number	:	615-444-3576
Fax Number	:	615-444-6374

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

Provider Enumeration Date	:	12/17/2011
Last Update Date	:	12/17/2011

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