Provider Demographics
NPI:1619431517
Name:MOORE, PHILIP BRETT (DOCTOR OF PHARMACY)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:BRETT
Last Name:MOORE
Suffix:
Gender:M
Credentials:DOCTOR OF PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:863 23RD AVE SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-2607
Mailing Address - Country:US
Mailing Address - Phone:814-316-6898
Mailing Address - Fax:952-888-6095
Practice Address - Street 1:200 AMERICAN BLVD W
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-1120
Practice Address - Country:US
Practice Address - Phone:952-888-6079
Practice Address - Fax:952-888-6095
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN121058183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN121058OtherSTATE PHARMACY LICENSE