Provider Demographics
NPI:1194008490
Name:HAILE, MELLAI Z (RPH)
Entity Type:Individual
Prefix:
First Name:MELLAI
Middle Name:Z
Last Name:HAILE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15390 NEW HALLS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-1327
Mailing Address - Country:US
Mailing Address - Phone:314-831-9916
Mailing Address - Fax:314-837-8542
Practice Address - Street 1:15390 NEW HALLS FERRY RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-1327
Practice Address - Country:US
Practice Address - Phone:314-831-9916
Practice Address - Fax:314-837-8542
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008027470183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO603942905Medicaid