MEDICARE: WADE LUCAS MOORE PHARMD

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	1835P1200X	Pharmacotherapy Pharmacist	17258	AL

General Provider Information

NPI Number	:	1588040463
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WADE LUCAS MOORE PHARMD

Provider Business Mailing Address
First Line	:	3952 US HIGHWAY 80 W
Second Line	:
City	:	PHENIX CITY
State	:	AL
Zip	:	36870-6523
Country	:	US
Telephone Number	:	334-214-9129
Fax Number	:	334-214-9640

Provider Business Practice Location Address
First Line	:	3952 US HIGHWAY 80 W
Second Line	:
City	:	PHENIX CITY
State	:	AL
Zip	:	36870-6523
Country	:	US
Telephone Number	:	334-214-9129
Fax Number	:	334-214-9640

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

Provider Enumeration Date	:	08/03/2015
Last Update Date	:	08/03/2015

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Directions to “ WADE LUCAS MOORE PHARMD” Practice Location

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