Provider Demographics
NPI:1427534361
Name:HILLESTAD, MARY LOUISE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:HILLESTAD
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:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:FRENCH VILLAGE
Mailing Address - State:MO
Mailing Address - Zip Code:63036-0099
Mailing Address - Country:US
Mailing Address - Phone:573-358-0864
Mailing Address - Fax:
Practice Address - Street 1:942 VALLEY CREEK DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1968
Practice Address - Country:US
Practice Address - Phone:573-664-5202
Practice Address - Fax:573-664-5203
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO026939183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist