Basic Information
| Provider Information | |||||||||
| NPI: | 1073502423 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMACIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 727 | ||||||||
| Address2: | PO BOX 727 | ||||||||
| City: | MARGARETVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124550727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455862631 | ||||||||
| FaxNumber: | 8455862631 | ||||||||
| Practice Location | |||||||||
| Address1: | RT 28 | ||||||||
| Address2: | RT 28 | ||||||||
| City: | MARGARETVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455862631 | ||||||||
| FaxNumber: | 8455862631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 36561 | NY | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.