Provider Demographics
NPI:1073669354
Name:MOORE, JACLYN LEE (PHARM D)
Entity Type:Individual
Prefix:MS
First Name:JACLYN
Middle Name:LEE
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 870
Mailing Address - Street 2:
Mailing Address - City:HONOKAA
Mailing Address - State:HI
Mailing Address - Zip Code:96727-0870
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:67-1185 MAMALAHOA HWY
Practice Address - Street 2:
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-7304
Practice Address - Country:US
Practice Address - Phone:808-885-2075
Practice Address - Fax:808-885-2061
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2525183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist