Provider Demographics
NPI:1831348630
Name:MOORE, JODY N
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:N
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 1:219 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49073-9577
Mailing Address - Country:US
Mailing Address - Phone:517-852-0845
Mailing Address - Fax:
Practice Address - Street 1:219 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:MI
Practice Address - Zip Code:49073-9577
Practice Address - Country:US
Practice Address - Phone:517-852-0845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030691183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist