Provider Demographics
NPI:1497362743
Name:HALL, MICHAEL TYLER
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TYLER
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 1:137 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:WHITESBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41858-7752
Mailing Address - Country:US
Mailing Address - Phone:606-634-7332
Mailing Address - Fax:
Practice Address - Street 1:9145 BEAUTY RD
Practice Address - Street 2:
Practice Address - City:WARFIELD
Practice Address - State:KY
Practice Address - Zip Code:41267-8302
Practice Address - Country:US
Practice Address - Phone:606-395-0522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY021695183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist