Provider Demographics
NPI:1851306476
Name:MOORE MED CNTR CLINIC PHCY
Entity Type:Organization
Organization Name:MOORE MED CNTR CLINIC PHCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORP DIR OF PHCY AND MATERIALS
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-917-0315
Mailing Address - Street 1:700 S TELEPHONE RD
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-2502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 S TELEPHONE RD
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-2502
Practice Address - Country:US
Practice Address - Phone:405-917-0315
Practice Address - Fax:405-917-0321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK75069333600000X
3336C0002X, 3336C0003X, 3336H0001X, 3336L0003X, 3336M0002X, 3336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0002XSuppliersPharmacyClinic Pharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Not Answered3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Not Answered3336M0002XSuppliersPharmacyMail Order Pharmacy
Not Answered3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3724552OtherOTHER ID NUMBER-COMMERCIAL NUMBER
5654950001Medicare ID - Type Unspecified