Healthcare Provider Details

I. General information

NPI: 1457793952
Provider Name (Legal Business Name): ANDREW MOSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2013
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

577 MEADOW ST.
CHICOPEE MA
01013-3120
US

IV. Provider business mailing address

577 MEADOW ST
CHICOPEE MA
01013-1876
US

V. Phone/Fax

Practice location:
  • Phone: 413-592-4696
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH234648
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: