Provider Demographics
NPI:1134216476
Name:MOORE, KRISTY LADAWN (RPH)
Entity type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:LADAWN
Last Name:MOORE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PARK VIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:MINNIE
Mailing Address - State:KY
Mailing Address - Zip Code:41651
Mailing Address - Country:US
Mailing Address - Phone:606-377-9216
Mailing Address - Fax:606-377-2118
Practice Address - Street 1:8274 KY RT 122
Practice Address - Street 2:
Practice Address - City:MINNIE
Practice Address - State:KY
Practice Address - Zip Code:41651
Practice Address - Country:US
Practice Address - Phone:606-377-2117
Practice Address - Fax:606-377-2118
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY12197183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY5401104400Medicaid
KY5564870001Medicare ID - Type Unspecified