Provider Demographics
NPI:1972060366
Name:MOORE, CLAY W (DPH)
Entity type:Individual
Prefix:
First Name:CLAY
Middle Name:W
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 1:11101 HEFNER POINTE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-5054
Mailing Address - Country:US
Mailing Address - Phone:405-850-5571
Mailing Address - Fax:
Practice Address - Street 1:11101 HEFNER POINTE DR STE 101
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-5054
Practice Address - Country:US
Practice Address - Phone:405-850-5571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10054183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100245800AMedicaid