Provider Demographics
NPI:1538529300
Name:MOORE, NATHANIEL RANDALL (PHARMD)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:RANDALL
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:NATHANIEL
Other - Middle Name:RANDALL
Other - Last Name:THOMPSON-MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:14311 SE AMBERLYN CT
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-7223
Mailing Address - Country:US
Mailing Address - Phone:281-794-5715
Mailing Address - Fax:
Practice Address - Street 1:1919 NW LOVEJOY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1503
Practice Address - Country:US
Practice Address - Phone:971-201-2640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-00145641835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist