Healthcare Provider Details

I. General information

NPI: 1760886048
Provider Name (Legal Business Name): ASHLEY DANIELLE HICKS PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY DANIELLE FARGEN PHARMD

II. Dates (important events)

Enumeration Date: 10/15/2014
Last Update Date: 10/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E SUPERIOR ST 15 PRENTICE PHARMACY
CHICAGO IL
60611-2914
US

IV. Provider business mailing address

250 E SUPERIOR ST 15 PRENTICE PHARMACY
CHICAGO IL
60611-2914
US

V. Phone/Fax

Practice location:
  • Phone: 312-472-3790
  • Fax:
Mailing address:
  • Phone: 312-472-3790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835X0200X
TaxonomyOncology Pharmacist
License Number051.296829
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1835X0200X
TaxonomyOncology Pharmacist
License Number16337-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: