Provider Demographics
NPI:1811267933
Name:HALL, DWAYNE KERRY (RPH)
Entity type:Individual
Prefix:MR
First Name:DWAYNE
Middle Name:KERRY
Last Name:HALL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4889 SAUK TRL
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1017
Mailing Address - Country:US
Mailing Address - Phone:708-748-6115
Mailing Address - Fax:708-748-6119
Practice Address - Street 1:4889 SAUK TRL
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-1017
Practice Address - Country:US
Practice Address - Phone:708-679-0598
Practice Address - Fax:708-679-0948
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2025-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.036399183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL361924025786Medicaid