Healthcare Provider Details

I. General information

NPI: 1427425289
Provider Name (Legal Business Name): MOSES MOFOR FOMA RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2015
Last Update Date: 08/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3041 N MAIN ST
LAS CRUCES NM
88001-1164
US

IV. Provider business mailing address

2775 N ROADRUNNER PKWY APT 1304
LAS CRUCES NM
88011-8121
US

V. Phone/Fax

Practice location:
  • Phone: 575-647-8878
  • Fax:
Mailing address:
  • Phone: 301-640-6528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00008111
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: