Provider Demographics
NPI:1922339886
Name:MOORE, RAY
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11420 S FORTUNA RD
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85367-5618
Mailing Address - Country:US
Mailing Address - Phone:928-342-1034
Mailing Address - Fax:928-342-1053
Practice Address - Street 1:11420 S FORTUNA RD
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85367-5618
Practice Address - Country:US
Practice Address - Phone:928-342-1034
Practice Address - Fax:928-342-1053
Is Sole Proprietor?:No
Enumeration Date:2010-01-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5680183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist