MEDICARE: DR. NICHOLAS ANTONIO MOORE DOCTOR OF PHARMACY

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	S022386	AZ
2	183500000X	Pharmacist	2016027148	MO

General Provider Information

NPI Number	:	1265042691
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICHOLAS ANTONIO MOORE DOCTOR OF PHARMACY

Provider Business Mailing Address
First Line	:	604 CHERRY DR
Second Line	:
City	:	FAIRVIEW HEIGHTS
State	:	IL
Zip	:	62208-2846
Country	:	US
Telephone Number	:	618-409-1573
Fax Number	:

Provider Business Practice Location Address
First Line	:	604 CHERRY DR
Second Line	:
City	:	FAIRVIEW HEIGHTS
State	:	IL
Zip	:	62208-2846
Country	:	US
Telephone Number	:	618-409-1573
Fax Number	:

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

Provider Enumeration Date	:	07/31/2020
Last Update Date	:	07/31/2020

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