Healthcare Provider Details

I. General information

NPI: 1396981312
Provider Name (Legal Business Name): DESAK G HICKS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2008
Last Update Date: 03/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

873 HIGHWAY 84
COFFEEVILLE AL
36524-5012
US

IV. Provider business mailing address

873 HIGHWAY 84
COFFEEVILLE AL
36524-5012
US

V. Phone/Fax

Practice location:
  • Phone: 251-276-3400
  • Fax: 251-276-3562
Mailing address:
  • Phone: 251-276-3400
  • Fax: 251-276-3562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11671
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number113345
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: