Healthcare Provider Details

I. General information

NPI: 1760081533
Provider Name (Legal Business Name): MICHAEL RAY MOORE CPHT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2020
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

179 KENT ST
BROOKLINE MA
02446-5463
US

IV. Provider business mailing address

179 KENT ST
BROOKLINE MA
02446-5463
US

V. Phone/Fax

Practice location:
  • Phone: 617-299-9131
  • Fax:
Mailing address:
  • Phone: 617-299-9131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number39282
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberVA61082215
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberPHA-PTE-LIC-83395
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: