=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023731130
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BREANNA BARBARA MOORE PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2022
-----------------------------------------------------
Last Update Date | 09/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2420 LINCOLN WAY
-----------------------------------------------------
City | AMES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50014-7448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-292-2990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4015 NE 5TH ST
-----------------------------------------------------
City | ANKENY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50021-6945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-235-6566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 24600
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------