Healthcare Provider Details

I. General information

NPI: 1396737169
Provider Name (Legal Business Name): ROBERT DALE HICKMAN RPH,MS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 4 BOX 1E
FAIRMONT WV
26554-9328
US

IV. Provider business mailing address

RR 4 BOX 1E
FAIRMONT WV
26554-9328
US

V. Phone/Fax

Practice location:
  • Phone: 304-366-8395
  • Fax: 304-366-8395
Mailing address:
  • Phone: 304-366-8395
  • Fax: 304-366-8395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4025
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: