1114929296 NPI number — MOFFETTRX LLC

Table of content: (NPI 1114929296)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114929296 NPI number — MOFFETTRX LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOFFETTRX LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114929296
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2000 24TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39301-3120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-693-0033
Provider Business Mailing Address Fax Number:
601-693-0062

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 24TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39301-3120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-693-0033
Provider Business Practice Location Address Fax Number:
601-693-0062
Provider Enumeration Date:
06/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MOFFETT
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
ANDREW
Authorized Official Title or Position:
PHARMACIST IN CHARGE/OWNER
Authorized Official Telephone Number:
601-693-0033

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  03424-01MM , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2518629 . This is a "NABP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00330246 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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