Provider Demographics
NPI:1164025904
Name:HALL, MICHAEL EDWARD
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EDWARD
Last Name:HALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:KY
Mailing Address - Zip Code:40444-1058
Mailing Address - Country:US
Mailing Address - Phone:859-792-4611
Mailing Address - Fax:
Practice Address - Street 1:330 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:KY
Practice Address - Zip Code:40444-1058
Practice Address - Country:US
Practice Address - Phone:859-792-4611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY009889183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist