Provider Demographics
NPI:1639869761
Name:HALL, MARY KAYE (RPH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KAYE
Last Name:HALL
Suffix:
Gender:F
Credentials:RPH
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 509
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:MO
Mailing Address - Zip Code:65459-0509
Mailing Address - Country:US
Mailing Address - Phone:573-759-3073
Mailing Address - Fax:573-759-3560
Practice Address - Street 1:508 E 5TH ST
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:MO
Practice Address - Zip Code:65459-6201
Practice Address - Country:US
Practice Address - Phone:573-759-3073
Practice Address - Fax:573-759-3560
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO042271183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist