Provider Demographics
NPI:1528260791
Name:HICKS, BARBARA TRAVIS (RPH)
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:TRAVIS
Last Name:HICKS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 CHIPPEWA ST
Mailing Address - Street 2:
Mailing Address - City:CLAWSON
Mailing Address - State:MI
Mailing Address - Zip Code:48017-2093
Mailing Address - Country:US
Mailing Address - Phone:248-835-9578
Mailing Address - Fax:
Practice Address - Street 1:11800 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3472
Practice Address - Country:US
Practice Address - Phone:586-573-5270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI24119183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist