Provider Demographics
NPI:1801064423
Name:MOORE, KIM ANN
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:ANN
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 1:54 OVERLOOK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-4849
Mailing Address - Country:US
Mailing Address - Phone:732-833-7326
Mailing Address - Fax:732-833-7326
Practice Address - Street 1:2006 HWY 35
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NJ
Practice Address - Zip Code:07762-2543
Practice Address - Country:US
Practice Address - Phone:732-282-0719
Practice Address - Fax:732-282-9069
Is Sole Proprietor?:No
Enumeration Date:2008-02-17
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040519183500000X
NJ28RI02876300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY040519Medicaid