Provider Demographics
NPI:1417001272
Name:MOORE HEALTHCARE, INC.
Entity Type:Organization
Organization Name:MOORE HEALTHCARE, INC.
Other - Org Name:PALACE DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:P
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-358-2587
Mailing Address - Street 1:301 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OK
Mailing Address - Zip Code:74020-3421
Mailing Address - Country:US
Mailing Address - Phone:918-358-2524
Mailing Address - Fax:918-358-2588
Practice Address - Street 1:301 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OK
Practice Address - Zip Code:74020-3421
Practice Address - Country:US
Practice Address - Phone:918-358-2524
Practice Address - Fax:918-358-2588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK332B00000X
OK52-4094332BP3500X, 3336C0003X
OK52-S-1138332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100811860AMedicaid
OK100811860BMedicaid
OK100811860Medicaid
OK3700499OtherPHARMACY NCPDP NUMBER
OK100811860BMedicaid
OK100811860AMedicaid