Healthcare Provider Details

I. General information

NPI: 1639869761
Provider Name (Legal Business Name): MARY KAYE HALL R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 E 5TH ST
DIXON MO
65459-6201
US

IV. Provider business mailing address

PO BOX 509
DIXON MO
65459-0509
US

V. Phone/Fax

Practice location:
  • Phone: 573-759-3073
  • Fax: 573-759-3560
Mailing address:
  • Phone: 573-759-3073
  • Fax: 573-759-3560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number042271
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: