Basic Information
| Provider Information | |||||||||
| NPI: | 1649491473 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HICKMAN COMMUNITY HEALTH SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ASCENSION SAINT THOMAS HICKMAN HOSPITAL PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 135 E SWAN ST | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370331417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317294271 | ||||||||
| FaxNumber: | 9317296814 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 E SWAN ST | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370331417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317294271 | ||||||||
| FaxNumber: | 9317296814 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 08/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6152846845 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | 234 | TN | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 4414037 | 01 | TN | NCPDP | OTHER |