Provider Demographics
NPI:1659954204
Name:MOORE, CHARLES GREGORY (RPH)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:GREGORY
Last Name:MOORE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22323 E VIA DEL JARDIN
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-1236
Mailing Address - Country:US
Mailing Address - Phone:636-290-9346
Mailing Address - Fax:
Practice Address - Street 1:22323 E VIA DEL JARDIN
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-1236
Practice Address - Country:US
Practice Address - Phone:636-290-9346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-02
Last Update Date:2021-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY009386183500000X
AZ16064183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist