Provider Demographics
NPI:1619301652
Name:MOORE, DANIEL JOSEPH (PHARMD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOSEPH
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N55W34835 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-2469
Mailing Address - Country:US
Mailing Address - Phone:262-408-8956
Mailing Address - Fax:
Practice Address - Street 1:2700 NEW PINERY RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9221
Practice Address - Country:US
Practice Address - Phone:608-742-5727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17086-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist