Provider Demographics
NPI:1184033813
Name:MOORE, BURL III
Entity Type:Individual
Prefix:
First Name:BURL
Middle Name:
Last Name:MOORE
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18071 US HIGHWAY 59
Mailing Address - Street 2:
Mailing Address - City:PARSONS
Mailing Address - State:KS
Mailing Address - Zip Code:67357-8035
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3201 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PARSONS
Practice Address - State:KS
Practice Address - Zip Code:67357-3472
Practice Address - Country:US
Practice Address - Phone:620-421-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-14269183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist