Healthcare Provider Details

I. General information

NPI: 1356439558
Provider Name (Legal Business Name): HICKSVILLE PHARMACY & HOME MEDICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 03/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 E HIGH ST
HICKSVILLE OH
43526-1107
US

IV. Provider business mailing address

116 E HIGH ST
HICKSVILLE OH
43526-1107
US

V. Phone/Fax

Practice location:
  • Phone: 419-542-6218
  • Fax: 419-542-8246
Mailing address:
  • Phone: 419-542-6218
  • Fax: 419-542-8246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number022091050
License Number StateOH

VIII. Authorized Official

Name: JONATHON M MYERS
Title or Position: OWNER
Credential:
Phone: 419-542-6218