Provider Demographics
NPI:1154832954
Name:MOORE, JERRY (DPH)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 N ACADEMY ST
Mailing Address - Street 2:
Mailing Address - City:GUYMON
Mailing Address - State:OK
Mailing Address - Zip Code:73942-2756
Mailing Address - Country:US
Mailing Address - Phone:580-338-8421
Mailing Address - Fax:580-338-0721
Practice Address - Street 1:1902 N ACADEMY ST
Practice Address - Street 2:
Practice Address - City:GUYMON
Practice Address - State:OK
Practice Address - Zip Code:73942-2756
Practice Address - Country:US
Practice Address - Phone:580-338-8421
Practice Address - Fax:580-338-0721
Is Sole Proprietor?:No
Enumeration Date:2017-10-19
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8564183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100235280AMedicaid