Provider Demographics
NPI:1770191918
Name:MOORE, MIRANDA (PHARMD)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3989
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-7989
Mailing Address - Country:US
Mailing Address - Phone:804-272-1423
Mailing Address - Fax:804-272-7967
Practice Address - Street 1:2608 BUFORD RD
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-3422
Practice Address - Country:US
Practice Address - Phone:804-272-1423
Practice Address - Fax:804-272-7967
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202218807183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist