Provider Demographics
NPI:1578997730
Name:MORENO, MARK JAMES (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JAMES
Last Name:MORENO
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6859 E SIMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-1448
Mailing Address - Country:US
Mailing Address - Phone:401-440-7807
Mailing Address - Fax:
Practice Address - Street 1:6859 E SIMPSON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-1448
Practice Address - Country:US
Practice Address - Phone:401-440-7807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-23
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68517183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist