Provider Demographics
NPI:1164638318
Name:MOORE, KIM CARLSON (RPH)
Entity Type:Individual
Prefix:MR
First Name:KIM
Middle Name:CARLSON
Last Name:MOORE
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 1:4950 QUAIL LN
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4436
Mailing Address - Country:US
Mailing Address - Phone:801-479-0996
Mailing Address - Fax:801-479-0996
Practice Address - Street 1:HARMON'S PHARMACY
Practice Address - Street 2:37 HARRISVILLE ROAD
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404
Practice Address - Country:US
Practice Address - Phone:801-621-2532
Practice Address - Fax:801-621-8716
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT139695-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist