Provider Demographics
NPI:1760081533
Name:MOORE, MICHAEL RAY (CPHT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:RAY
Last Name:MOORE
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 KENT ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-5463
Mailing Address - Country:US
Mailing Address - Phone:617-299-9131
Mailing Address - Fax:
Practice Address - Street 1:179 KENT ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5463
Practice Address - Country:US
Practice Address - Phone:617-299-9131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-22
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39282183700000X
WAVA61082215183700000X
MTPHA-PTE-LIC-83395183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician