Healthcare Provider Details

I. General information

NPI: 1154723070
Provider Name (Legal Business Name): JERRY P MOORE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 09/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 N BROAD ST
SEAGROVE NC
27341-8583
US

IV. Provider business mailing address

510 N BROAD ST
SEAGROVE NC
27341-8583
US

V. Phone/Fax

Practice location:
  • Phone: 336-873-8246
  • Fax: 336-873-8608
Mailing address:
  • Phone: 336-873-8246
  • Fax: 336-873-8608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14929
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: