Healthcare Provider Details

I. General information

NPI: 1588768543
Provider Name (Legal Business Name): MOOSE DRUG COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 04/02/2020
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 MAIN ST W
LOCUST NC
28097-9793
US

IV. Provider business mailing address

1750 MAIN ST W
LOCUST NC
28097-9793
US

V. Phone/Fax

Practice location:
  • Phone: 704-888-2114
  • Fax: 704-888-2125
Mailing address:
  • Phone: 704-888-2114
  • Fax: 704-888-2125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number07108
License Number StateNC

VIII. Authorized Official

Name: RHONDA LYNN DARBY
Title or Position: PHARMACY MANAGER
Credential:
Phone: 704-888-2114