Provider Demographics
NPI:1588721963
Name:DENNIS TRENT MOSER
Entity type:Organization
Organization Name:DENNIS TRENT MOSER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:D TRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-549-6115
Mailing Address - Street 1:PO BOX 600
Mailing Address - Street 2:
Mailing Address - City:FLETCHER
Mailing Address - State:OK
Mailing Address - Zip Code:73541-0600
Mailing Address - Country:US
Mailing Address - Phone:580-549-6115
Mailing Address - Fax:580-549-6558
Practice Address - Street 1:428 E COLE
Practice Address - Street 2:
Practice Address - City:FLETCHER
Practice Address - State:OK
Practice Address - Zip Code:73541
Practice Address - Country:US
Practice Address - Phone:580-549-6115
Practice Address - Fax:580-549-6558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK3-32153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100235920AMedicaid
3712343OtherNCPDP PROVIDER IDENTIFICATION NUMBER
3712343OtherNCPDP PROVIDER IDENTIFICATION NUMBER