Provider Demographics
NPI:1174776470
Name:MOORE, MARY ANNE (PHARM D, RPH)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHARM D, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12400 E MARGINAL WAY S
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98168-2559
Mailing Address - Country:US
Mailing Address - Phone:206-901-4509
Mailing Address - Fax:
Practice Address - Street 1:12400 E MARGINAL WAY S
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98168-2559
Practice Address - Country:US
Practice Address - Phone:206-901-4509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 00056720183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist