Provider Demographics
NPI:1679617492
Name:MOORE HEALTHCARE, INC.
Entity Type:Organization
Organization Name:MOORE HEALTHCARE, INC.
Other - Org Name:MOORE HEALTHCARE, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:918-358-2524
Mailing Address - Street 1:301 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OK
Mailing Address - Zip Code:74020-3421
Mailing Address - Country:US
Mailing Address - Phone:918-358-2587
Mailing Address - Fax:918-358-2588
Practice Address - Street 1:301 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OK
Practice Address - Zip Code:74020-3421
Practice Address - Country:US
Practice Address - Phone:918-358-2587
Practice Address - Fax:918-358-2588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK332B00000X
OK52-4094333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100811860AMedicaid