Provider Demographics
NPI:1427596964
Name:MOORE, TSUBASA
Entity Type:Individual
Prefix:
First Name:TSUBASA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 ROOD AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-7819
Mailing Address - Country:US
Mailing Address - Phone:970-241-2278
Mailing Address - Fax:970-241-9277
Practice Address - Street 1:200 ROOD AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-7819
Practice Address - Country:US
Practice Address - Phone:970-241-2278
Practice Address - Fax:970-241-9277
Is Sole Proprietor?:No
Enumeration Date:2017-02-04
Last Update Date:2017-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18923183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist