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General NPI Number Information
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NPI Number | 1942310404
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Entity Type | Individual
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Provider Name | STACEY MOORE
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Gender | Female
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Dates
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Enumeration Date | 08/30/2006
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Last Update Date | 11/27/2020
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Provider Practice Location Address
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Address Line | 111 8TH ST E
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City | TIFTON
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State | GA
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Zip | 31794-4099
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Country | US
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Telephone | 229-382-4541
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Fax | 229-388-1909
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Provider Business Mailing Address
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Address Line | 366 GOSS DR
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City | ASHBURN
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State | GA
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Zip | 31714-5111
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Country | US
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Telephone | 229-567-1161
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Fax |
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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 | 019515
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License Number State | GA
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