Provider Demographics
NPI:1568161289
Name:HALL, BRANDY NICOLE
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:NICOLE
Last Name:HALL
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 1:780 CECIL ST
Mailing Address - Street 2:
Mailing Address - City:PENNINGTON GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24277-1279
Mailing Address - Country:US
Mailing Address - Phone:276-219-2398
Mailing Address - Fax:
Practice Address - Street 1:4500 W STONE DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-1049
Practice Address - Country:US
Practice Address - Phone:423-245-6839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN46765183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN46765OtherLICENSE NUMBER