Provider Demographics
NPI:1093271843
Name:FANNING, HALLIE RAE (PHARM D)
Entity Type:Individual
Prefix:MISS
First Name:HALLIE
Middle Name:RAE
Last Name:FANNING
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2260 HEPPERMAN RD
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-5314
Mailing Address - Country:US
Mailing Address - Phone:573-202-9152
Mailing Address - Fax:636-278-4754
Practice Address - Street 1:522 N NEW BALLAS RD STE 206
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6819
Practice Address - Country:US
Practice Address - Phone:314-499-1227
Practice Address - Fax:314-499-1228
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20180246311835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist