Provider Demographics
NPI:1679514962
Name:HALEY, HAMILTON YORK (DPH)
Entity Type:Individual
Prefix:
First Name:HAMILTON
Middle Name:YORK
Last Name:HALEY
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:673 PITTS RD
Mailing Address - Street 2:P.O. BOX 66
Mailing Address - City:FRIENDSHIP
Mailing Address - State:TN
Mailing Address - Zip Code:38034-3070
Mailing Address - Country:US
Mailing Address - Phone:731-677-2925
Mailing Address - Fax:731-677-2252
Practice Address - Street 1:548 MAIN ST
Practice Address - Street 2:BOX 66
Practice Address - City:FRIENDSHIP
Practice Address - State:TN
Practice Address - Zip Code:38034-1966
Practice Address - Country:US
Practice Address - Phone:731-677-2155
Practice Address - Fax:731-677-2252
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3244183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4406446OtherNCPDP
TN4406446Medicaid
4406446OtherNCPDP