Provider Demographics
NPI:1003101221
Name:MOORE, WILLIAM SAMUEL JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:SAMUEL
Last Name:MOORE
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:111 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORDTON
Mailing Address - State:NC
Mailing Address - Zip Code:28139-2904
Mailing Address - Country:US
Mailing Address - Phone:828-287-1043
Mailing Address - Fax:828-286-9826
Practice Address - Street 1:111 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RUTHERFORDTON
Practice Address - State:NC
Practice Address - Zip Code:28139-2904
Practice Address - Country:US
Practice Address - Phone:828-287-1043
Practice Address - Fax:828-286-9826
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC07964183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0815142Medicaid