Provider Demographics
NPI:1811168610
Name:MOORE, PATRICK SETH
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:SETH
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 E CRESTWOOD CT
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-7120
Mailing Address - Country:US
Mailing Address - Phone:910-890-1955
Mailing Address - Fax:
Practice Address - Street 1:220 E CRESTWOOD CT
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-7120
Practice Address - Country:US
Practice Address - Phone:910-890-1955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19180183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist