Provider Demographics
NPI:1164018479
Name:HARTLEY, WANDA COOK (RPH)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:COOK
Last Name:HARTLEY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:CAROL
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:2231 EL DORADO DR
Mailing Address - Street 2:
Mailing Address - City:NESBIT
Mailing Address - State:MS
Mailing Address - Zip Code:38651-9569
Mailing Address - Country:US
Mailing Address - Phone:662-654-1790
Mailing Address - Fax:
Practice Address - Street 1:1502 GOODMAN RD W
Practice Address - Street 2:
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-1407
Practice Address - Country:US
Practice Address - Phone:662-342-6436
Practice Address - Fax:662-342-6667
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR15569183500000X
AL18175183500000X
TN36488183500000X
LAPST.020401183500000X
MSE06619183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist