Provider Demographics
NPI:1528386315
Name:MOORE, JOHNNY ALLEN (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:ALLEN
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4715 NINE MILE RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-4908
Mailing Address - Country:US
Mailing Address - Phone:804-822-2057
Mailing Address - Fax:
Practice Address - Street 1:4715 NINE MILE RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-4908
Practice Address - Country:US
Practice Address - Phone:804-822-2057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02004479183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist