Provider Demographics
NPI:1396068490
Name:MOE, RICHARD DONALD (RPH)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:DONALD
Last Name:MOE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2631 TOWER AVE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-4846
Mailing Address - Country:US
Mailing Address - Phone:715-392-0487
Mailing Address - Fax:175-392-1754
Practice Address - Street 1:2631 TOWER AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-4846
Practice Address - Country:US
Practice Address - Phone:715-392-0487
Practice Address - Fax:175-392-1754
Is Sole Proprietor?:No
Enumeration Date:2010-03-04
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11924-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist