=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700314093
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER ASHLEY MOORE PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2017
-----------------------------------------------------
Last Update Date | 05/31/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5100 HIGHWAY 39 N
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39301-1023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-485-0818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 LONGWOOD DR
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39305-8231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-242-9598
-----------------------------------------------------
Fax | 205-242-9598
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | E-010852
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------