Basic Information
| Provider Information | |||||||||
| NPI: | 1932201779 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICKS | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARM.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8352 ROY LN | ||||||||
| Address2: | |||||||||
| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373639247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239022942 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1030 JEFFERSON AVE | ||||||||
| Address2: | PHARMACY | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381042127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015238990 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 26984 | TN | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.