Healthcare Provider Details

I. General information

NPI: 1639464878
Provider Name (Legal Business Name): FREDDIE VERNELL MOYER JR. PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2011
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 GRACELAND BLVD T-1978
COLUMBUS OH
43214-7508
US

IV. Provider business mailing address

55 GRACELAND BLVD T-1978
COLUMBUS OH
43214-7508
US

V. Phone/Fax

Practice location:
  • Phone: 614-781-9407
  • Fax: 614-781-9407
Mailing address:
  • Phone: 614-781-9407
  • Fax: 614-781-9407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03318478
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: