Provider Demographics
NPI:1013402809
Name:MOORE, KAILEY LYNN
Entity Type:Individual
Prefix:
First Name:KAILEY
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-4445
Mailing Address - Country:US
Mailing Address - Phone:208-681-8233
Mailing Address - Fax:
Practice Address - Street 1:376 WEST 18TH STREET
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402
Practice Address - Country:US
Practice Address - Phone:208-681-8233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP8030183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist