Provider Demographics
NPI:1790288405
Name:HALL, CARDELL JR (PHARM D)
Entity Type:Individual
Prefix:
First Name:CARDELL
Middle Name:
Last Name:HALL
Suffix:JR
Gender:M
Credentials:PHARM D
Other - Prefix:DR
Other - First Name:CARDELL
Other - Middle Name:
Other - Last Name:HALL
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:PHARM D
Mailing Address - Street 1:2508 W HUNTSVILLE ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-6124
Mailing Address - Country:US
Mailing Address - Phone:918-863-4676
Mailing Address - Fax:
Practice Address - Street 1:1400 E DOWNING ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464
Practice Address - Country:US
Practice Address - Phone:918-456-2355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR-17684183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist