Provider Demographics
NPI:1629236807
Name:MOODY, JANE ELIZABETH (RPH)
Entity Type:Individual
Prefix:MRS
First Name:JANE
Middle Name:ELIZABETH
Last Name:MOODY
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 1:35 S JOHNSON ST
Mailing Address - Street 2:SUITE 1E
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-1658
Mailing Address - Country:US
Mailing Address - Phone:248-334-9582
Mailing Address - Fax:248-334-1908
Practice Address - Street 1:35 S JOHNSON ST
Practice Address - Street 2:SUITE 1E
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1658
Practice Address - Country:US
Practice Address - Phone:248-334-9582
Practice Address - Fax:248-334-1908
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-24
Last Update Date:2008-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027506183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist