Provider Demographics
NPI:1497341630
Name:MOORE, DWAYNE
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 NEWMAN RD
Mailing Address - Street 2:
Mailing Address - City:LA MARQUE
Mailing Address - State:TX
Mailing Address - Zip Code:77568-3439
Mailing Address - Country:US
Mailing Address - Phone:409-938-1149
Mailing Address - Fax:409-877-1557
Practice Address - Street 1:204 NEWMAN RD
Practice Address - Street 2:
Practice Address - City:LA MARQUE
Practice Address - State:TX
Practice Address - Zip Code:77568-3439
Practice Address - Country:US
Practice Address - Phone:409-938-1149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX47644183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty