Provider Demographics
NPI:1558450098
Name:MOORE, WILLIAM DAVID SR (RPH)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:DAVID
Last Name:MOORE
Suffix:SR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1281 MADELYN LN
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:GA
Mailing Address - Zip Code:30650-3417
Mailing Address - Country:US
Mailing Address - Phone:706-342-3835
Mailing Address - Fax:706-342-9159
Practice Address - Street 1:1400 EATONTON RD STE 600
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:GA
Practice Address - Zip Code:30650-4625
Practice Address - Country:US
Practice Address - Phone:706-342-2070
Practice Address - Fax:706-342-9159
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA705139183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist