Provider Demographics
NPI:1255631958
Name:MOODY, ANN MARIE NICOLE (RPH)
Entity type:Individual
Prefix:MRS
First Name:ANN MARIE
Middle Name:NICOLE
Last Name:MOODY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MS
Other - First Name:ANN MARIE
Other - Middle Name:NICOLE
Other - Last Name:BURAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:411 E MAIN ST
Mailing Address - Street 2:P O DRAWER 1003
Mailing Address - City:OAK GROVE
Mailing Address - State:LA
Mailing Address - Zip Code:71263-2552
Mailing Address - Country:US
Mailing Address - Phone:318-428-4205
Mailing Address - Fax:318-428-4207
Practice Address - Street 1:411 E MAIN ST
Practice Address - Street 2:P O DRAWER 1003
Practice Address - City:OAK GROVE
Practice Address - State:LA
Practice Address - Zip Code:71263-2552
Practice Address - Country:US
Practice Address - Phone:318-428-4205
Practice Address - Fax:318-428-4207
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA18288183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist