Provider Demographics
NPI:1962514505
Name:MOORE, RYAN DAVID (RPH, MBA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:DAVID
Last Name:MOORE
Suffix:
Gender:M
Credentials:RPH, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-1363
Mailing Address - Country:US
Mailing Address - Phone:269-673-6749
Mailing Address - Fax:269-673-9491
Practice Address - Street 1:100 MONROE ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1363
Practice Address - Country:US
Practice Address - Phone:269-673-6749
Practice Address - Fax:269-673-9491
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030586183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist