Provider Demographics
NPI:1700480639
Name:MOORE, STEPHANIE RENEE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:RENEE
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18048 JEFFERSON DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:RUTHER GLEN
Mailing Address - State:VA
Mailing Address - Zip Code:22546-2922
Mailing Address - Country:US
Mailing Address - Phone:804-448-3216
Mailing Address - Fax:804-212-1268
Practice Address - Street 1:18048 JEFFERSON DAVIS HWY
Practice Address - Street 2:
Practice Address - City:RUTHER GLEN
Practice Address - State:VA
Practice Address - Zip Code:22546-2922
Practice Address - Country:US
Practice Address - Phone:804-448-3216
Practice Address - Fax:804-212-1268
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-22
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202212314183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist