Provider Demographics
NPI:1104124486
Name:MOSELEY, JOHN BRYAN (PHARMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:BRYAN
Last Name:MOSELEY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4809 PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-8802
Mailing Address - Country:US
Mailing Address - Phone:912-852-4007
Mailing Address - Fax:912-685-2388
Practice Address - Street 1:705 S LEWIS ST
Practice Address - Street 2:
Practice Address - City:METTER
Practice Address - State:GA
Practice Address - Zip Code:30439-5128
Practice Address - Country:US
Practice Address - Phone:912-685-6337
Practice Address - Fax:912-685-6327
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-10
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332B00000X
GA021744183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003142233AMedicaid