Provider Demographics
NPI:1497357388
Name:MOORE, MOLLY CATHRYN
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:CATHRYN
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 1:4805 W FARM ROAD 156
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MO
Mailing Address - Zip Code:65619-9575
Mailing Address - Country:US
Mailing Address - Phone:417-860-3225
Mailing Address - Fax:
Practice Address - Street 1:2681 W REPUBLIC RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-4006
Practice Address - Country:US
Practice Address - Phone:417-877-8540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-15
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020002801183500000X
MO2023039438183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist