Basic Information
| Provider Information | |||||||||
| NPI: | 1013249507 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | MIRANDA | ||||||||
| MiddleName: | BETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.PH. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 550 S. PEORIA AVENUE | ||||||||
| Address2: | INDIAN HEALTH CARE RESOURCE CENTER OF TULSA | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741203820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185881900 | ||||||||
| FaxNumber: | 9185826405 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 S. PEORIA AVENUE | ||||||||
| Address2: | INDIAN HEALTH CARE RESOURCE CENTER OF TULSA | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741203820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185881900 | ||||||||
| FaxNumber: | 9185826405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2010 | ||||||||
| LastUpdateDate: | 02/08/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 14068 | OK | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.