Provider Demographics
NPI:1255829222
Name:MOORE, JOHN RUSSELL (RPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RUSSELL
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 1:1626 HIGHWAY 12 S
Mailing Address - Street 2:
Mailing Address - City:ASHLAND CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37015-3322
Mailing Address - Country:US
Mailing Address - Phone:615-792-7720
Mailing Address - Fax:615-792-5346
Practice Address - Street 1:1626 HIGHWAY 12 S
Practice Address - Street 2:
Practice Address - City:ASHLAND CITY
Practice Address - State:TN
Practice Address - Zip Code:37015-3322
Practice Address - Country:US
Practice Address - Phone:615-792-7720
Practice Address - Fax:615-792-5346
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4906183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist