Provider Demographics
NPI:1023566163
Name:MOELLER, DEVERA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DEVERA
Middle Name:
Last Name:MOELLER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 BEAUMONT CT
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-8186
Mailing Address - Country:US
Mailing Address - Phone:770-721-4190
Mailing Address - Fax:770-720-5455
Practice Address - Street 1:201 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2408
Practice Address - Country:US
Practice Address - Phone:770-721-4190
Practice Address - Fax:770-720-5455
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHH004103282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital