1124067640 NPI number — CHRISTINE CAROLE HICKS RPH

Table of content: CHRISTINE CAROLE HICKS RPH (NPI 1124067640)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124067640 NPI number — CHRISTINE CAROLE HICKS RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HICKS
Provider First Name:
CHRISTINE
Provider Middle Name:
CAROLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RPH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124067640
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8855 SW BRABHAM WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GASTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97119-9025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-985-0140
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1152 BASELINE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORNELIUS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97113-9019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-352-8553
Provider Business Practice Location Address Fax Number:
503-352-8554
Provider Enumeration Date:
06/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  RPH-0009911 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 183500000X , with the licence number: PH00017057 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PH00017057 . This is a "PHARMACIST LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: RPH-0009911 . This is a "PHARMACIST LICENSE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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