Provider Demographics
NPI:1821526948
Name:MOORE, COREY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-4260
Mailing Address - Country:US
Mailing Address - Phone:903-533-0367
Mailing Address - Fax:
Practice Address - Street 1:11937 US HIGHWAY 271
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75708-3154
Practice Address - Country:US
Practice Address - Phone:903-877-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-02
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63524183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX63524Medicaid