MEDICARE: THOMAS ANDREW MOAK III D.PH.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	C7809	TN

General Provider Information

NPI Number	:	1184626038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS ANDREW MOAK III D.PH.

Provider Business Mailing Address
First Line	:	315 WARWICK WAY
Second Line	:
City	:	SEYMOUR
State	:	TN
Zip	:	37865-6145
Country	:	US
Telephone Number	:	865-579-1852
Fax Number	:

Provider Business Practice Location Address
First Line	:	3588 WORKMAN RD
Second Line	:	SUITE 101
City	:	KNOXVILLE
State	:	TN
Zip	:	37921-5932
Country	:	US
Telephone Number	:	865-558-8733
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	07/08/2007

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