Healthcare Provider Details

I. General information

NPI: 1306017595
Provider Name (Legal Business Name): JON GARY HICKS PHARMACY TECHNICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2008
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 THREE SONS DR
BIRMINGHAM AL
35226-2961
US

IV. Provider business mailing address

146 THREE SONS DR
BIRMINGHAM AL
35226-2961
US

V. Phone/Fax

Practice location:
  • Phone: 205-824-9086
  • Fax:
Mailing address:
  • Phone: 205-824-9086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberT02361
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: