Provider Demographics
NPI:1164991782
Name:MORENO, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MORENO
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 1:3755 RUCKER DR
Mailing Address - Street 2:
Mailing Address - City:TIMMONSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29161-9224
Mailing Address - Country:US
Mailing Address - Phone:843-472-1218
Mailing Address - Fax:
Practice Address - Street 1:615 BULTMAN DR
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-2514
Practice Address - Country:US
Practice Address - Phone:803-305-6194
Practice Address - Fax:803-305-6197
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37860183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC37860OtherSC PHARMACIST LICENSE