Provider Demographics
NPI:1588978910
Name:MOORE, LEIGH
Entity type:Individual
Prefix:
First Name:LEIGH
Middle Name:
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 1:413 W HURON ST
Mailing Address - Street 2:
Mailing Address - City:MISSOURI VALLEY
Mailing Address - State:IA
Mailing Address - Zip Code:51555-1436
Mailing Address - Country:US
Mailing Address - Phone:712-642-2716
Mailing Address - Fax:712-642-3961
Practice Address - Street 1:413 W HURON ST
Practice Address - Street 2:
Practice Address - City:MISSOURI VALLEY
Practice Address - State:IA
Practice Address - Zip Code:51555-1436
Practice Address - Country:US
Practice Address - Phone:712-642-2716
Practice Address - Fax:712-642-3961
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19464183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist