Provider Demographics
NPI:1396340972
Name:HALL, KODY
Entity type:Individual
Prefix:
First Name:KODY
Middle Name:
Last Name:HALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7428 EASTPORT PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:LA VISTA
Mailing Address - State:NE
Mailing Address - Zip Code:68128-2348
Mailing Address - Country:US
Mailing Address - Phone:402-991-7283
Mailing Address - Fax:402-991-7281
Practice Address - Street 1:7428 EASTPORT PKWY STE 101
Practice Address - Street 2:
Practice Address - City:LA VISTA
Practice Address - State:NE
Practice Address - Zip Code:68128-2348
Practice Address - Country:US
Practice Address - Phone:402-991-7283
Practice Address - Fax:402-991-7281
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13485183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist