Provider Demographics
NPI:1811978083
Name:MOORE DRUG STORE, INC.
Entity type:Organization
Organization Name:MOORE DRUG STORE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:COTNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-454-5210
Mailing Address - Street 1:608 W MARKLAND AVE
Mailing Address - Street 2:STE A
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-6110
Mailing Address - Country:US
Mailing Address - Phone:765-454-5210
Mailing Address - Fax:765-454-5209
Practice Address - Street 1:608 W MARKLAND AVE
Practice Address - Street 2:STE A
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-6110
Practice Address - Country:US
Practice Address - Phone:765-454-5210
Practice Address - Fax:765-454-5209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0216260001Medicare ID - Type Unspecified