MEDICARE: CHANNA HENRY MOORE

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	0202-011338	VA

General Provider Information

NPI Number	:	1780946392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANNA HENRY MOORE

Provider Business Mailing Address
First Line	:	1671 CRYSTAL SQUARE ARC
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22202-3322
Country	:	US
Telephone Number	:	703-413-0525
Fax Number	:

Provider Business Practice Location Address
First Line	:	1671 CRYSTAL SQUARE ARC
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22202-3322
Country	:	US
Telephone Number	:	703-413-0525
Fax Number	:

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

Provider Enumeration Date	:	06/10/2012
Last Update Date	:	06/10/2012

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Directions to “ CHANNA HENRY MOORE ” Practice Location

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