Provider Demographics
NPI:1184052870
Name:MOORE, KATHERINE RUTH
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:RUTH
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:PO BOX 1877
Mailing Address - Street 2:
Mailing Address - City:MANTEO
Mailing Address - State:NC
Mailing Address - Zip Code:27954-1877
Mailing Address - Country:US
Mailing Address - Phone:252-473-5056
Mailing Address - Fax:252-473-6430
Practice Address - Street 1:1115 SOUTH US HIGHWAY 64
Practice Address - Street 2:
Practice Address - City:MANTEO
Practice Address - State:NC
Practice Address - Zip Code:27954
Practice Address - Country:US
Practice Address - Phone:252-473-5056
Practice Address - Fax:252-473-6430
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16101183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0285114Medicaid