Provider Demographics
NPI:1336411826
Name:MOORE, SAMMY DEWAYNE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SAMMY
Middle Name:DEWAYNE
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:TX
Mailing Address - Zip Code:76446-1158
Mailing Address - Country:US
Mailing Address - Phone:254-445-4411
Mailing Address - Fax:254-965-8409
Practice Address - Street 1:110 SCENIC DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:TX
Practice Address - Zip Code:76446-1158
Practice Address - Country:US
Practice Address - Phone:254-445-4411
Practice Address - Fax:254-965-8409
Is Sole Proprietor?:No
Enumeration Date:2012-01-31
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35220183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX35220OtherTEXAS STATE BOARD OF PHARMACY