Provider Demographics
NPI:1699100578
Name:HICKERSON, KIMLY (PHARMACIST)
Entity type:Individual
Prefix:
First Name:KIMLY
Middle Name:
Last Name:HICKERSON
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 S BROADVIEW ST STE 11&12
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5760
Mailing Address - Country:US
Mailing Address - Phone:573-803-5000
Mailing Address - Fax:573-803-5501
Practice Address - Street 1:121 S BROADVIEW ST STE 11&12
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5760
Practice Address - Country:US
Practice Address - Phone:573-803-5500
Practice Address - Fax:573-803-5501
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY010303183500000X
MO043576183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist