MEDICARE: JENNIFER M HICKS PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	2011007381	MO
2	183500000X	Pharmacist	RPH025063	GA

General Provider Information

NPI Number	:	1578844718
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER M HICKS PHARMD

Provider Business Mailing Address
First Line	:	PO BOX 762
Second Line	:
City	:	MOBERLY
State	:	MO
Zip	:	65270-0762
Country	:	US
Telephone Number	:	912-660-9976
Fax Number	:

Provider Business Practice Location Address
First Line	:	1711 N MORLEY ST
Second Line	:
City	:	MOBERLY
State	:	MO
Zip	:	65270-3630
Country	:	US
Telephone Number	:	660-263-0793
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2011
Last Update Date	:	09/01/2011

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