Provider Demographics
NPI:1275130585
Name:SMITH, HALEY MARIE
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 RANDOLPH AVE
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-3948
Mailing Address - Country:US
Mailing Address - Phone:304-636-5696
Mailing Address - Fax:304-636-3363
Practice Address - Street 1:505 RANDOLPH AVE
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3948
Practice Address - Country:US
Practice Address - Phone:304-636-5696
Practice Address - Fax:304-646-3363
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0010243183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1598868242Medicaid