Provider Demographics
NPI:1184103806
Name:MOORE, CARLA CONNIE (PD)
Entity type:Individual
Prefix:DR
First Name:CARLA
Middle Name:CONNIE
Last Name:MOORE
Suffix:
Gender:F
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 RIVER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-2084
Mailing Address - Country:US
Mailing Address - Phone:479-629-4780
Mailing Address - Fax:479-484-5515
Practice Address - Street 1:4900 ROGERS AVE STE 101J
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2068
Practice Address - Country:US
Practice Address - Phone:479-484-9125
Practice Address - Fax:479-484-5515
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10607183500000X
ARPD07574183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR135322407Medicaid
1467471441OtherNPI