Healthcare Provider Details

I. General information

NPI: 1811800584
Provider Name (Legal Business Name): LILLIE MOORE PHARMD STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3690 EAST AVE
ROCHESTER NY
14618-3597
US

IV. Provider business mailing address

213 CHESTNUT ST
ELMIRA NY
14904-1206
US

V. Phone/Fax

Practice location:
  • Phone: 585-385-8000
  • Fax:
Mailing address:
  • Phone: 607-377-2027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: