Healthcare Provider Details

I. General information

NPI: 1538858394
Provider Name (Legal Business Name): MOSS HOLLAND ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11621 RAINWOOD RD STE 7
LITTLE ROCK AR
72212-3947
US

IV. Provider business mailing address

PO BOX 21294
LITTLE ROCK AR
72221-1294
US

V. Phone/Fax

Practice location:
  • Phone: 501-222-1002
  • Fax: 501-222-1807
Mailing address:
  • Phone: 803-447-1959
  • Fax: 501-222-1807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MARK HOLLAND
Title or Position: PARTNER
Credential: PHARMD
Phone: 803-447-1959