Provider Demographics
NPI:1982798351
Name:MOORE, MICHAEL BRAXTON (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:BRAXTON
Last Name:MOORE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:401 BICENTENNIAL WAY
Mailing Address - Street 2:SUITE 195
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2149
Mailing Address - Country:US
Mailing Address - Phone:707-393-3472
Mailing Address - Fax:
Practice Address - Street 1:401 BICENTENNIAL WAY
Practice Address - Street 2:SUITE 195
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2149
Practice Address - Country:US
Practice Address - Phone:707-393-4000
Practice Address - Fax:707-393-4660
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH0390151835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy