Provider Demographics
NPI:1669537304
Name:MOORE, RANDALL R (RPH)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:R
Last Name:MOORE
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 1:19054 PINE RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-5274
Mailing Address - Country:US
Mailing Address - Phone:208-798-5293
Mailing Address - Fax:
Practice Address - Street 1:720 16TH AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-3768
Practice Address - Country:US
Practice Address - Phone:208-743-5528
Practice Address - Fax:208-746-2785
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP3855183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP3855OtherSTATE LICENSE NO