=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225514375
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANE M FICKES PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2018
-----------------------------------------------------
Last Update Date | 04/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 724 S CENTRAL AVE STE 101G
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97501-7808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-329-0478
-----------------------------------------------------
Fax | 541-314-9556
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 724 S CENTRAL AVE STE 101G
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97501-7808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-329-0478
-----------------------------------------------------
Fax | 541-314-9556
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | RPH-0016659
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------