Provider Demographics
NPI:1063435527
Name:MOORE, CHARLES LEON (RPH)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:LEON
Last Name:MOORE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 S DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:NE
Mailing Address - Zip Code:68467-3902
Mailing Address - Country:US
Mailing Address - Phone:402-362-6499
Mailing Address - Fax:402-362-4980
Practice Address - Street 1:2029 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:NE
Practice Address - Zip Code:68467-1025
Practice Address - Country:US
Practice Address - Phone:402-362-4429
Practice Address - Fax:402-362-4980
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8476183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE8476OtherSTATE PHARMACY LICENSE