Provider Demographics
NPI:1043877533
Name:MOORE, WILLIAM D (PHARMD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:D
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 12TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1285
Mailing Address - Country:US
Mailing Address - Phone:580-223-5828
Mailing Address - Fax:580-226-3902
Practice Address - Street 1:1316 12TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1285
Practice Address - Country:US
Practice Address - Phone:580-223-5828
Practice Address - Fax:580-226-3902
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13246183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist