Provider Demographics
NPI:1295011989
Name:MOORE, JASON LLOYD (PHARMD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:LLOYD
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 HIGHWAY 110
Mailing Address - Street 2:
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55120-1509
Mailing Address - Country:US
Mailing Address - Phone:651-414-3787
Mailing Address - Fax:
Practice Address - Street 1:790 HIGHWAY 110
Practice Address - Street 2:
Practice Address - City:MENDOTA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55120-1509
Practice Address - Country:US
Practice Address - Phone:651-414-3787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120158183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist