Healthcare Provider Details

I. General information

NPI: 1134182827
Provider Name (Legal Business Name): DESAK G HICKS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2006
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 TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number110452
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number110452
License Number StateAL

VIII. Authorized Official

Name: MR. DESAK GEORGE HICKS
Title or Position: OWNER/PHARMACIST
Credential:
Phone: 251-276-3400