Provider Demographics
NPI:1124476130
Name:HICKS, JODI LYNN I
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:LYNN
Last Name:HICKS
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4522 ELKHART RD
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-5822
Mailing Address - Country:US
Mailing Address - Phone:574-875-3010
Mailing Address - Fax:574-875-3065
Practice Address - Street 1:4522 ELKHART RD
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-5822
Practice Address - Country:US
Practice Address - Phone:574-875-3010
Practice Address - Fax:574-875-3065
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26017560A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist