Provider Demographics
NPI:1679391197
Name:MOORE, JERRY (RPH)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8121 BROADWAY ST STE 109
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77061-1340
Mailing Address - Country:US
Mailing Address - Phone:281-888-7163
Mailing Address - Fax:346-330-9852
Practice Address - Street 1:8121 BROADWAY ST STE 109
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77061-1340
Practice Address - Country:US
Practice Address - Phone:281-888-7163
Practice Address - Fax:346-330-9852
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37476183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist