MEDICARE: JOHNNY MIKE HICKS II

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	PD11945	AR

General Provider Information

NPI Number	:	1871193847
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNNY MIKE HICKS II

Provider Business Mailing Address
First Line	:	3081 N HIGHWAY 112
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72704-7436
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3081 N HIGHWAY 112
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72704-7436
Country	:	US
Telephone Number	:	479-587-1853
Fax Number	:

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

Provider Enumeration Date	:	10/29/2020
Last Update Date	:	10/29/2020

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