Provider Demographics
NPI:1336648526
Name:MOODY, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:MOODY
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 1:1210 MINERAL WELLS AVE
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TN
Mailing Address - Zip Code:38242-4914
Mailing Address - Country:US
Mailing Address - Phone:731-644-0220
Mailing Address - Fax:
Practice Address - Street 1:1210 MINERAL WELLS AVE
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TN
Practice Address - Zip Code:38242-4914
Practice Address - Country:US
Practice Address - Phone:731-644-0220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10607183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist