Basic Information
| Provider Information | |||||||||
| NPI: | 1184103806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | CONNIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1702 RIVER RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | VAN BUREN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729562084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796294780 | ||||||||
| FaxNumber: | 4794845515 | ||||||||
| Practice Location | |||||||||
| Address1: | 4900 ROGERS AVE STE 101J | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729032068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794849125 | ||||||||
| FaxNumber: | 4794845515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2018 | ||||||||
| LastUpdateDate: | 08/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 10607 | OK | N | Pharmacy Service Providers | Pharmacist | 183500000X | PD07574 | AR | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 135322407 | 05 | AR | MEDICAID | 1467471441 | 01 | NPI | OTHER |