Provider Demographics
NPI:1376810713
Name:MOORE, MICHAEL CHARLES (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CHARLES
Last Name:MOORE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:CHARLES
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:2201 S LOOP 256
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-4701
Mailing Address - Country:US
Mailing Address - Phone:903-723-4705
Mailing Address - Fax:
Practice Address - Street 1:2201 S LOOP 256
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-4701
Practice Address - Country:US
Practice Address - Phone:903-723-4705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22298183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist