Provider Demographics
NPI:1457816290
Name:MOORE, JEFFREY EDWARD (DPH)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:EDWARD
Last Name:MOORE
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OK
Mailing Address - Zip Code:74020-3421
Mailing Address - Country:US
Mailing Address - Phone:918-358-2524
Mailing Address - Fax:918-358-2588
Practice Address - Street 1:301 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OK
Practice Address - Zip Code:74020-3421
Practice Address - Country:US
Practice Address - Phone:918-358-2524
Practice Address - Fax:918-358-2588
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10598183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist