Provider Demographics
NPI:1194764167
Name:HICKMANS PRESCRIPTION DRUGGIST INC
Entity type:Organization
Organization Name:HICKMANS PRESCRIPTION DRUGGIST INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-425-2188
Mailing Address - Street 1:199 12TH STREET EXT
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2352
Mailing Address - Country:US
Mailing Address - Phone:304-425-2188
Mailing Address - Fax:304-425-2189
Practice Address - Street 1:199 12TH STREET EXT
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2352
Practice Address - Country:US
Practice Address - Phone:304-425-2188
Practice Address - Fax:304-425-2189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
WVSP05501203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2109476OtherPK
WV0141947000Medicaid
WV0141947000Medicaid