Provider Demographics
NPI:1386017200
Name:MOYERS, MARK ANTHONY (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:MOYERS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1191 STONO MTN DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-7733
Mailing Address - Country:US
Mailing Address - Phone:314-885-4961
Mailing Address - Fax:314-919-9672
Practice Address - Street 1:1191 STONO MTN DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-7733
Practice Address - Country:US
Practice Address - Phone:314-885-4961
Practice Address - Fax:314-919-9672
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO043068183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist