Healthcare Provider Details

I. General information

NPI: 1801733092
Provider Name (Legal Business Name): CHESTER LEE MOORE JR. CPHT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 AMES CROSSING RD # 200
EAGAN MN
55121-2498
US

IV. Provider business mailing address

2900 AMES CROSSING RD # 200
EAGAN MN
55121-2498
US

V. Phone/Fax

Practice location:
  • Phone: 855-457-0007
  • Fax:
Mailing address:
  • Phone: 855-457-0007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number049246810
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: