Provider Demographics
NPI:1144615956
Name:MOYER, MYRTLE JOLYNN
Entity Type:Individual
Prefix:DR
First Name:MYRTLE
Middle Name:JOLYNN
Last Name:MOYER
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 1:105 SUMAC ST
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-4562
Mailing Address - Country:US
Mailing Address - Phone:979-215-9286
Mailing Address - Fax:
Practice Address - Street 1:105 SUMAC ST
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-4562
Practice Address - Country:US
Practice Address - Phone:979-215-9286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41694183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist