Provider Demographics
NPI:1225121338
Name:MOORE PHARMACY SERVICE; LLC
Entity Type:Organization
Organization Name:MOORE PHARMACY SERVICE; LLC
Other - Org Name:SELECT RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-461-8103
Mailing Address - Street 1:11414 E. 51ST STREET
Mailing Address - Street 2:UNIT A
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5821
Mailing Address - Country:US
Mailing Address - Phone:918-461-8103
Mailing Address - Fax:918-461-9795
Practice Address - Street 1:11414 E. 51ST STREET
Practice Address - Street 2:UNIT A
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-5821
Practice Address - Country:US
Practice Address - Phone:918-461-8103
Practice Address - Fax:918-461-9795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24-6103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100247400BMedicaid
OK100247400AMedicaid
OK100247400BMedicaid