Healthcare Provider Details

I. General information

NPI: 1639963648
Provider Name (Legal Business Name): JACI MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 07/19/2026
Certification Date: 07/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11300 CORPORATE AVE STE 120
LENEXA KS
66219-1365
US

IV. Provider business mailing address

202 OAK CT
HALLSVILLE MO
65255-9472
US

V. Phone/Fax

Practice location:
  • Phone: 913-574-0600
  • Fax:
Mailing address:
  • Phone: 573-228-1374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1-128462
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: