Provider Demographics
NPI:1720122336
Name:MOORE, MICHAEL BRENT (DPH)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRENT
Last Name:MOORE
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 DORSETT CT
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-9000
Mailing Address - Country:US
Mailing Address - Phone:918-335-6688
Mailing Address - Fax:918-335-9787
Practice Address - Street 1:3400 E FRANK PHILLIPS BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2495
Practice Address - Country:US
Practice Address - Phone:918-331-2525
Practice Address - Fax:918-335-2589
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10778183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist