Healthcare Provider Details

I. General information

NPI: 1427534361
Provider Name (Legal Business Name): MARY LOUISE HILLESTAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2018
Last Update Date: 07/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

942 VALLEY CREEK DR
FARMINGTON MO
63640-1968
US

IV. Provider business mailing address

PO BOX 99
FRENCH VILLAGE MO
63036-0099
US

V. Phone/Fax

Practice location:
  • Phone: 573-664-5202
  • Fax: 573-664-5203
Mailing address:
  • Phone: 573-358-0864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number026939
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: