Provider Demographics
NPI:1528810686
Name:MOORE, BRETT MICHAEL (PHARMD)
Entity type:Individual
Prefix:DR
First Name:BRETT
Middle Name:MICHAEL
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 CANTERBURY BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-3202
Mailing Address - Country:US
Mailing Address - Phone:740-649-6469
Mailing Address - Fax:
Practice Address - Street 1:4120 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1230
Practice Address - Country:US
Practice Address - Phone:260-484-7021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH034439391835P0018X
IN26030571A1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist