Provider Demographics
NPI:1205952587
Name:MOORE, VANESSA RAE (RPH)
Entity type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:RAE
Last Name:MOORE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MRS
Other - First Name:VANESSA
Other - Middle Name:RAE
Other - Last Name:DUPREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:105 OHIO STREET
Mailing Address - Street 2:
Mailing Address - City:MILLINOCKET
Mailing Address - State:ME
Mailing Address - Zip Code:04462-1935
Mailing Address - Country:US
Mailing Address - Phone:207-233-4769
Mailing Address - Fax:207-723-9548
Practice Address - Street 1:843 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:MILLINOCKET
Practice Address - State:ME
Practice Address - Zip Code:04462-2125
Practice Address - Country:US
Practice Address - Phone:207-723-8148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR5047183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist