Healthcare Provider Details

I. General information

NPI: 1376865865
Provider Name (Legal Business Name): KATHERINE MARIE HICKS CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2010
Last Update Date: 02/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 PUBLIC SQUARE
STOCKTON MO
65785
US

IV. Provider business mailing address

PO BOX 189
STOCKTON MO
65785-0189
US

V. Phone/Fax

Practice location:
  • Phone: 417-276-3128
  • Fax: 417-276-4914
Mailing address:
  • Phone: 417-276-3128
  • Fax: 417-276-4914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number210119156157679
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: