Provider Demographics
NPI:1982600953
Name:MOORE, ANTHONY RAY (RPH)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:RAY
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 1:1311 EDWIN MILLER BLVD
Mailing Address - Street 2:OLD COUTHOUSE SQ
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25404-3703
Mailing Address - Country:US
Mailing Address - Phone:304-264-0300
Mailing Address - Fax:304-264-0224
Practice Address - Street 1:1311 OLD COURTHOUSE SQ
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25404
Practice Address - Country:US
Practice Address - Phone:304-264-0300
Practice Address - Fax:304-264-0224
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0005165183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVRP0005165OtherBOARD OF PHARMACY LICENSE