Provider Demographics
NPI:1598123796
Name:MOORE, ELLEN (RPH)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 S COLLINS RD
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:KY
Mailing Address - Zip Code:41034-9618
Mailing Address - Country:US
Mailing Address - Phone:606-407-5130
Mailing Address - Fax:
Practice Address - Street 1:381 MARKET SQUARE DR
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-8721
Practice Address - Country:US
Practice Address - Phone:606-759-7973
Practice Address - Fax:606-759-2031
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY010552183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist