Healthcare Provider Details

I. General information

NPI: 1235241613
Provider Name (Legal Business Name): RODNEY L MOORE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 HIGHWAY 16 E
CARTHAGE MS
39051-4245
US

IV. Provider business mailing address

811 HIGHWAY 16 E
CARTHAGE MS
39051-4245
US

V. Phone/Fax

Practice location:
  • Phone: 601-267-8078
  • Fax: 601-267-6886
Mailing address:
  • Phone: 601-267-8078
  • Fax: 601-267-6886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. RODNEY L MOORE
Title or Position: OWNER
Credential: R. PH.
Phone: 601-625-7158