Provider Demographics
NPI:1972103158
Name:MOORE, TAMMI D
Entity Type:Individual
Prefix:
First Name:TAMMI
Middle Name:D
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 IRVING CT
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-3694
Mailing Address - Country:US
Mailing Address - Phone:304-612-7776
Mailing Address - Fax:304-366-1583
Practice Address - Street 1:32 TYGART MALL LOOP
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-2187
Practice Address - Country:US
Practice Address - Phone:304-366-9115
Practice Address - Fax:304-366-1583
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0005951183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist