MEDICARE: DR. CARLA CONNIE MOORE PD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	10607	OK
2	183500000X	Pharmacist	PD07574	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1467471441	OTHER		NPI

General Provider Information

NPI Number	:	1184103806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARLA CONNIE MOORE PD

Provider Business Mailing Address
First Line	:	1702 RIVER RIDGE RD
Second Line	:
City	:	VAN BUREN
State	:	AR
Zip	:	72956-2084
Country	:	US
Telephone Number	:	479-629-4780
Fax Number	:	479-484-5515

Provider Business Practice Location Address
First Line	:	4900 ROGERS AVE STE 101J
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-2068
Country	:	US
Telephone Number	:	479-484-9125
Fax Number	:	479-484-5515

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2018
Last Update Date	:	08/13/2018

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