Provider Demographics
NPI:1366043945
Name:MOORE, CHASE (PHARMD)
Entity Type:Individual
Prefix:
First Name:CHASE
Middle Name:
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 1:1621 FIELDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-6602
Mailing Address - Country:US
Mailing Address - Phone:660-341-7399
Mailing Address - Fax:
Practice Address - Street 1:1100 LEJUNE DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-4537
Practice Address - Country:US
Practice Address - Phone:217-529-7193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012028249183500000X
IL051.297383183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist