Provider Demographics
NPI:1376556910
Name:MOORE, RANDAL E (DPH)
Entity Type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:E
Last Name:MOORE
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:OK
Mailing Address - Zip Code:73030-1904
Mailing Address - Country:US
Mailing Address - Phone:580-369-2831
Mailing Address - Fax:580-369-2614
Practice Address - Street 1:218 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:OK
Practice Address - Zip Code:73030-1904
Practice Address - Country:US
Practice Address - Phone:580-369-2831
Practice Address - Fax:580-369-2614
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7560183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist