Healthcare Provider Details

I. General information

NPI: 1619049137
Provider Name (Legal Business Name): MICHELLE MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7107 CHARLESTON HWY
BOWMAN SC
29018
US

IV. Provider business mailing address

4257 HERITAGE HWY
BAMBERG SC
29003-9199
US

V. Phone/Fax

Practice location:
  • Phone: 803-829-2547
  • Fax:
Mailing address:
  • Phone: 803-245-0920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number10119
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: