Healthcare Provider Details

I. General information

NPI: 1932219888
Provider Name (Legal Business Name): MOOSE DRUG COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8374 W FRANKLIN ST
MT PLEASANT NC
28124-8812
US

IV. Provider business mailing address

PO BOX 67
MT PLEASANT NC
28124-0067
US

V. Phone/Fax

Practice location:
  • Phone: 704-436-9613
  • Fax: 704-436-6512
Mailing address:
  • Phone:
  • Fax:

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 TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number05395
License Number StateNC

VIII. Authorized Official

Name: WILLIAM MOOSE JR.
Title or Position: OWNER PHARMACY MANAGER
Credential: RPH
Phone: 704-436-9613