Provider Demographics
NPI:1194943225
Name:MOORE, IVY D (PD)
Entity type:Individual
Prefix:DR
First Name:IVY
Middle Name:D
Last Name:MOORE
Suffix:
Gender:F
Credentials:PD
Other - Prefix:DR
Other - First Name:FLOYD
Other - Middle Name:D
Other - Last Name:TYE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 597
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71754
Mailing Address - Country:US
Mailing Address - Phone:870-234-1062
Mailing Address - Fax:
Practice Address - Street 1:134 N WASHINGTON
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-2856
Practice Address - Country:US
Practice Address - Phone:870-234-1062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD07920183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist