Provider Demographics
NPI:1619049137
Name:MOORE, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
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 1:4257 HERITAGE HWY
Mailing Address - Street 2:
Mailing Address - City:BAMBERG
Mailing Address - State:SC
Mailing Address - Zip Code:29003-9199
Mailing Address - Country:US
Mailing Address - Phone:803-245-0920
Mailing Address - Fax:
Practice Address - Street 1:7107 CHARLESTON HWY
Practice Address - Street 2:
Practice Address - City:BOWMAN
Practice Address - State:SC
Practice Address - Zip Code:29018
Practice Address - Country:US
Practice Address - Phone:803-829-2547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10119183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC10119OtherPHARMACY TECH ID