=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417824038
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW HICKSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2025
-----------------------------------------------------
Last Update Date | 10/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 MICHIGAN ST NE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49503-2560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-391-1774
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8731 FLAT CREEK DR UNIT K
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49341-8945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-629-9816
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5302417651
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------