Provider Demographics
NPI:1174170054
Name:HALL, STACEY (RPH)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:
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 1:5188 S 200 E
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-8354
Mailing Address - Country:US
Mailing Address - Phone:317-468-8674
Mailing Address - Fax:
Practice Address - Street 1:263 W MORGAN ST
Practice Address - Street 2:
Practice Address - City:KNIGHTSTOWN
Practice Address - State:IN
Practice Address - Zip Code:46148-9312
Practice Address - Country:US
Practice Address - Phone:765-345-7163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-24
Last Update Date:2019-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26022440A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist