Provider Demographics
NPI:1306185392
Name:MOORE, JAMES LEE (RPH)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:LEE
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 1:111 SAND LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-2760
Mailing Address - Country:US
Mailing Address - Phone:608-775-8563
Mailing Address - Fax:
Practice Address - Street 1:111 SAND LAKE RD
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-2760
Practice Address - Country:US
Practice Address - Phone:608-775-8563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-11
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12416183500000X
GA13944183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist