Provider Demographics
NPI:1386247989
Name:MOORE, RICKETA (PHARMD)
Entity type:Individual
Prefix:
First Name:RICKETA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:RICKETA
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD
Mailing Address - Street 1:7325 JONESBORO RD
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-2950
Mailing Address - Country:US
Mailing Address - Phone:678-422-4854
Mailing Address - Fax:678-422-5025
Practice Address - Street 1:7325 JONESBORO RD
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-2950
Practice Address - Country:US
Practice Address - Phone:678-422-4854
Practice Address - Fax:678-422-5025
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
GARPH023368183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy