Healthcare Provider Details

I. General information

NPI: 1124067640
Provider Name (Legal Business Name): CHRISTINE CAROLE HICKS RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1152 BASELINE
CORNELIUS OR
97113-9019
US

IV. Provider business mailing address

8855 SW BRABHAM WAY
GASTON OR
97119-9025
US

V. Phone/Fax

Practice location:
  • Phone: 503-352-8553
  • Fax: 503-352-8554
Mailing address:
  • Phone: 503-985-0140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH-0009911
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH00017057
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: