Basic Information
| Provider Information | |||||||||
| NPI: | 1407378193 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | ABIGAIL | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1775 LINNERUD DR APT 106 | ||||||||
| Address2: | |||||||||
| City: | SUN PRAIRIE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535903610 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | S2845 WHITE EAGLE RD | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539139064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083555177 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2017 | ||||||||
| LastUpdateDate: | 07/13/2017 | ||||||||
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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 | 18960-40 | WI | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 18960-40 | 01 | WI | STATE OF WISCONSIN LICENSE | OTHER |