Provider Demographics
NPI:1093091050
Name:MOE, DOUGLAS EDWIN (RPH)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:EDWIN
Last Name:MOE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 E SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2221
Mailing Address - Country:US
Mailing Address - Phone:218-724-3060
Mailing Address - Fax:
Practice Address - Street 1:1131 E SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2221
Practice Address - Country:US
Practice Address - Phone:218-724-3060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-22
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114336183500000X
WI13231-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist