Healthcare Provider Details

I. General information

NPI: 1811599434
Provider Name (Legal Business Name): CHELSI MOSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 11/09/2020
Certification Date: 11/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WALMART PHARMACY 800 E MAIN ST
LOCUST GROVE OK
74352
US

IV. Provider business mailing address

123 N VANN ST
PRYOR OK
74361-2423
US

V. Phone/Fax

Practice location:
  • Phone: 918-479-4815
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17044
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: