MEDICARE: MOORE'S PHARMACY LENA LLC

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

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

General Provider Information

NPI Number	:	1568012383
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOORE'S PHARMACY LENA LLC

Provider Business Mailing Address
First Line	:	PO BOX 80
Second Line	:
City	:	LENA
State	:	MS
Zip	:	39094-0080
Country	:	US
Telephone Number	:	601-780-2757
Fax Number	:	601-724-9438

Provider Business Practice Location Address
First Line	:	1212 GRAND AVENUE
Second Line	:
City	:	LENA
State	:	MS
Zip	:	39094
Country	:	US
Telephone Number	:	601-780-2757
Fax Number	:	601-724-9438

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. BRETT CHAPIN MOORE
Credential	:	PHARMD
Telephone Number	:	601-706-5417

Provider Enumeration Date	:	09/13/2019
Last Update Date	:	09/29/2020

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