Healthcare Provider Details

I. General information

NPI: 1982976288
Provider Name (Legal Business Name): MOOSE PHARMACY OF KANNAPOLIS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2012
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 N MAIN ST
KANNAPOLIS NC
28081-2256
US

IV. Provider business mailing address

1113 N MAIN ST
KANNAPOLIS NC
28081-2256
US

V. Phone/Fax

Practice location:
  • Phone: 704-932-9111
  • Fax: 704-932-0197
Mailing address:
  • Phone: 704-932-9111
  • Fax: 704-932-0197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KYLE YODER
Title or Position: TREASURER
Credential:
Phone: 704-636-6340