Provider Demographics
NPI:1619175866
Name:CARROLL, MISTY MAREE (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:MISTY
Middle Name:MAREE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:KY
Mailing Address - Zip Code:42347-1129
Mailing Address - Country:US
Mailing Address - Phone:270-298-3279
Mailing Address - Fax:270-298-3278
Practice Address - Street 1:312 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:KY
Practice Address - Zip Code:42347-1129
Practice Address - Country:US
Practice Address - Phone:270-298-3279
Practice Address - Fax:270-298-3278
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY013664183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY013664OtherKENTUCKY BOARD OF PHARMAC