Healthcare Provider Details

I. General information

NPI: 1700867918
Provider Name (Legal Business Name): MOORE DRUG STORE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 N BALDWIN AVE
MARION IN
46952-2534
US

IV. Provider business mailing address

608 W MARKLAND AVE STE A
KOKOMO IN
46901-6110
US

V. Phone/Fax

Practice location:
  • Phone: 765-733-0140
  • Fax: 765-733-0141
Mailing address:
  • Phone: 765-454-5210
  • Fax: 765-454-5209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MS. SARAH ELIZABETH COTNER
Title or Position: VICE-PRESIDENT
Credential:
Phone: 765-454-5210