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General NPI Number Information
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NPI Number | 1265779102
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Entity Type | Individual
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Provider Name | MRS. SHANNON RENEE MOORE
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Gender | Female
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Dates
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Enumeration Date | 01/11/2013
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Last Update Date | 09/26/2024
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Provider Practice Location Address
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Address Line | 13775 US 19 S
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City | THOMASVILLE
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State | GA
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Zip | 31792-5398
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Country | US
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Telephone | 229-228-6419
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Fax | 229-269-4422
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Provider Business Mailing Address
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Address Line | 3330 INNER PERIMETER RD
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City | VALDOSTA
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State | GA
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Zip | 31602
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Country | US
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Telephone | 229-671-9840
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Fax | 229-269-4422
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | RPH020367
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License Number State | GA
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