MEDICARE: MARK ANTHONY EASTMAN 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	183500000X	Pharmacist	RPH019761	GA

General Provider Information

NPI Number	:	1851996888
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK ANTHONY EASTMAN MOORE

Provider Business Mailing Address
First Line	:	19 WILLOW LAKE DR
Second Line	:	WARNER ROBINS
City	:	WARNER ROBINS
State	:	GA
Zip	:	31093
Country	:	US
Telephone Number	:	404-889-5600
Fax Number	:

Provider Business Practice Location Address
First Line	:	802 N HOUSTON RD
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31093-1502
Country	:	US
Telephone Number	:	478-923-5501
Fax Number	:	478-923-5944

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

Provider Enumeration Date	:	11/30/2020
Last Update Date	:	11/30/2020

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