Provider Demographics
NPI:1407224207
Name:MORAN, BETTINA (PHARMD)
Entity Type:Individual
Prefix:
First Name:BETTINA
Middle Name:
Last Name:MORAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11228 OLD HWY 63 SOUTH
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-4636
Mailing Address - Country:US
Mailing Address - Phone:601-947-4287
Mailing Address - Fax:
Practice Address - Street 1:11228 OLD HWY 63 SOUTH
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-4636
Practice Address - Country:US
Practice Address - Phone:601-947-4287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist