Provider Demographics
NPI:1326329574
Name:MOORE, AMBER DAWN
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:DAWN
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 1:2100 N SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:ARKANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67005-3855
Mailing Address - Country:US
Mailing Address - Phone:620-441-0283
Mailing Address - Fax:620-441-0887
Practice Address - Street 1:2100 N SUMMIT ST
Practice Address - Street 2:
Practice Address - City:ARKANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:67005-3855
Practice Address - Country:US
Practice Address - Phone:620-441-0283
Practice Address - Fax:620-441-0887
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-13864183500000X
OK13530183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist