Provider Demographics
NPI:1417313784
Name:MOORE, KELLEY NICOLE (PHARMD)
Entity Type:Individual
Prefix:MISS
First Name:KELLEY
Middle Name:NICOLE
Last Name:MOORE
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 1:3745 LOUISIANA AVE S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-4361
Mailing Address - Country:US
Mailing Address - Phone:952-926-0170
Mailing Address - Fax:952-926-1125
Practice Address - Street 1:3745 LOUISIANA AVE S
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-4361
Practice Address - Country:US
Practice Address - Phone:952-926-0170
Practice Address - Fax:952-926-1125
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-02
Last Update Date:2016-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN121059183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist