Provider Demographics
NPI:1942310404
Name:MOORE, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 GOSS DR
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:GA
Mailing Address - Zip Code:31714-5111
Mailing Address - Country:US
Mailing Address - Phone:229-567-1161
Mailing Address - Fax:
Practice Address - Street 1:111 8TH ST E
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-4099
Practice Address - Country:US
Practice Address - Phone:229-382-4541
Practice Address - Fax:229-388-1909
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019515183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA05012015Medicaid