MEDICARE: LARRY 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	183700000X	Pharmacy Technician

General Provider Information

NPI Number	:	1396915211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARRY MOORE

Provider Business Mailing Address
First Line	:	1060 WOOD STREAM DR
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-8837
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1060 WOOD STREAM DR
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-8837
Country	:	US
Telephone Number	:	469-371-9740
Fax Number	:

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

Provider Enumeration Date	:	03/06/2008
Last Update Date	:	03/06/2008

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Directions to “ LARRY MOORE ” Practice Location

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