Provider Demographics
NPI:1629363858
Name:MOORE, SCOTT
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 S RIVER RD
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-2116
Mailing Address - Country:US
Mailing Address - Phone:435-627-2037
Mailing Address - Fax:
Practice Address - Street 1:275 S RIVER RD
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2116
Practice Address - Country:US
Practice Address - Phone:435-627-2037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5660841183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist