Provider Demographics
NPI:1740733039
Name:MOORE, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
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 1:324 PENN ST
Mailing Address - Street 2:
Mailing Address - City:NEW BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:16242-1046
Mailing Address - Country:US
Mailing Address - Phone:814-275-4141
Mailing Address - Fax:
Practice Address - Street 1:132 W MAHONING ST
Practice Address - Street 2:
Practice Address - City:PUNXSUTAWNEY
Practice Address - State:PA
Practice Address - Zip Code:15767-2017
Practice Address - Country:US
Practice Address - Phone:814-938-3077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP043302L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist