Provider Demographics
NPI:1740622414
Name:MOORE, MILLER LEE (RPH)
Entity type:Individual
Prefix:
First Name:MILLER
Middle Name:LEE
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:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:ENERGY
Mailing Address - State:IL
Mailing Address - Zip Code:62933-0279
Mailing Address - Country:US
Mailing Address - Phone:618-942-4631
Mailing Address - Fax:618-988-1309
Practice Address - Street 1:639 N PERSHING ST
Practice Address - Street 2:
Practice Address - City:ENERGY
Practice Address - State:IL
Practice Address - Zip Code:62933-3606
Practice Address - Country:US
Practice Address - Phone:618-942-4631
Practice Address - Fax:618-988-1309
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051032648183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist