Provider Demographics
NPI:1265042691
Name:MOORE, NICHOLAS ANTONIO (DOCTOR OF PHARMACY)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:ANTONIO
Last Name:MOORE
Suffix:
Gender:M
Credentials:DOCTOR OF PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 CHERRY DR
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-2846
Mailing Address - Country:US
Mailing Address - Phone:618-409-1573
Mailing Address - Fax:
Practice Address - Street 1:604 CHERRY DR
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2846
Practice Address - Country:US
Practice Address - Phone:618-409-1573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS022386183500000X
MO2016027148183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist