Provider Demographics
NPI:1679306971
Name:MOORE, MADISON ROSE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:ROSE
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 1:280 MAIN RD APT 2
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04461-3242
Mailing Address - Country:US
Mailing Address - Phone:207-248-2488
Mailing Address - Fax:
Practice Address - Street 1:900 STILLWATER AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3602
Practice Address - Country:US
Practice Address - Phone:207-947-5811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR72130183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist