Basic Information
| Provider Information | |||||||||
| NPI: | 1619431517 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | BRETT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DOCTOR OF PHARMACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 863 23RD AVE SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554142607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143166898 | ||||||||
| FaxNumber: | 9528886095 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 AMERICAN BLVD W | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554201120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528886079 | ||||||||
| FaxNumber: | 9528886095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2019 | ||||||||
| LastUpdateDate: | 01/24/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 121058 | MN | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 121058 | 01 | MN | STATE PHARMACY LICENSE | OTHER |