Provider Demographics
NPI:1053524009
Name:RODNEY L MOORE
Entity type:Organization
Organization Name:RODNEY L MOORE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:C
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:601-706-5417
Mailing Address - Street 1:PO BOX 289
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:MS
Mailing Address - Zip Code:39359-0289
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16831 HWY 21 S
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:MS
Practice Address - Zip Code:39359
Practice Address - Country:US
Practice Address - Phone:601-625-7158
Practice Address - Fax:601-625-9480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS021783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00030128Medicaid
MS2511473OtherNCPDP
MS00030128Medicaid