MEDICARE: RODNEY L MOORE

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	3336C0003X	Community/Retail Pharmacy	02381	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2517968	OTHER	MS	NCPDP

General Provider Information

NPI Number	:	1376633818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RODNEY L MOORE

Provider Business Mailing Address
First Line	:	PO BOX 369
Second Line	:
City	:	WALNUT GROVE
State	:	MS
Zip	:	39189-0369
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	103 CHADWICK AVE
Second Line	:
City	:	WALNUT GROVE
State	:	MS
Zip	:	39189
Country	:	US
Telephone Number	:	601-253-2599
Fax Number	:	601-253-2182

Authorized Official
Title or Position	:	OWNER
Name	:	MR. RODNEY L MOORE
Credential	:	RPH
Telephone Number	:	601-625-7158

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	01/30/2019

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Directions to “RODNEY L MOORE ” Practice Location

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