Provider Demographics
NPI:1265034599
Name:MOORE, MARY ELIZABETH
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:MOORE
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 1:1812 OLD MAYLAND CT
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23294-4664
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4201 MEADOWDALE BLVD
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23234-5465
Practice Address - Country:US
Practice Address - Phone:804-271-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202219235183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist