MEDICARE: JOHN PHILLIP MOSS DPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	8916	OK

General Provider Information

NPI Number	:	1902974132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN PHILLIP MOSS DPH

Provider Business Mailing Address
First Line	:	11120 SE 49TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73150-3901
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	249 N DOUGLAS BLVD
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73130-3309
Country	:	US
Telephone Number	:	405-741-4411
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	07/08/2007

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