Healthcare Provider Details

I. General information

NPI: 1659984532
Provider Name (Legal Business Name): MOSES KWABENA OWUSU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 N ALPINE RD
ROCKFORD IL
61107-3613
US

IV. Provider business mailing address

1145 N ALPINE RD
ROCKFORD IL
61107-3613
US

V. Phone/Fax

Practice location:
  • Phone: 815-398-2443
  • Fax:
Mailing address:
  • Phone: 815-398-2443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26026015A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051-298198
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: