Provider Demographics
NPI:1063093052
Name:MOORE, KRISTEN (CPHT)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25738 CONNERY DR
Mailing Address - Street 2:
Mailing Address - City:FLAT ROCK
Mailing Address - State:MI
Mailing Address - Zip Code:48134-1816
Mailing Address - Country:US
Mailing Address - Phone:662-524-5435
Mailing Address - Fax:
Practice Address - Street 1:26100 VREELAND RD
Practice Address - Street 2:
Practice Address - City:FLAT ROCK
Practice Address - State:MI
Practice Address - Zip Code:48134-1692
Practice Address - Country:US
Practice Address - Phone:734-984-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303034532183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician