Healthcare Provider Details

I. General information

NPI: 1235027368
Provider Name (Legal Business Name): LATISHA HALL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2025
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1173 E HINES ST
REPUBLIC MO
65738-1277
US

IV. Provider business mailing address

1173 E HINES ST
REPUBLIC MO
65738-1277
US

V. Phone/Fax

Practice location:
  • Phone: 417-735-0055
  • Fax:
Mailing address:
  • Phone: 417-735-0055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number2022033873
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: