Provider Demographics
NPI:1356335921
Name:HALL, LEWIS ALLEN (RPH)
Entity type:Individual
Prefix:
First Name:LEWIS
Middle Name:ALLEN
Last Name:HALL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:LEWIS
Other - Middle Name:ALLEN
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5013 GRANBURY RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-2016
Mailing Address - Country:US
Mailing Address - Phone:817-441-5211
Mailing Address - Fax:817-441-5257
Practice Address - Street 1:5013 GRANBURY RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-2016
Practice Address - Country:US
Practice Address - Phone:817-441-5211
Practice Address - Fax:817-441-5257
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2019-08-23
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-12
Provider Licenses
StateLicense IDTaxonomies
TX20447183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142449Medicaid