Provider Demographics
NPI:1396498291
Name:MOORE, ZANDRELL
Entity type:Individual
Prefix:
First Name:ZANDRELL
Middle Name:
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 1:340 LAKERIDGE CT
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-3934
Mailing Address - Country:US
Mailing Address - Phone:470-458-8701
Mailing Address - Fax:
Practice Address - Street 1:340 LAKERIDGE CT
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-3934
Practice Address - Country:US
Practice Address - Phone:470-458-8701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHTC011724183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician