Provider Demographics
NPI:1588768543
Name:MOOSE DRUG COMPANY
Entity type:Organization
Organization Name:MOOSE DRUG COMPANY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DARBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-888-2114
Mailing Address - Street 1:1750 MAIN ST W
Mailing Address - Street 2:
Mailing Address - City:LOCUST
Mailing Address - State:NC
Mailing Address - Zip Code:28097-9793
Mailing Address - Country:US
Mailing Address - Phone:704-888-2114
Mailing Address - Fax:704-888-2125
Practice Address - Street 1:1750 MAIN ST W
Practice Address - Street 2:
Practice Address - City:LOCUST
Practice Address - State:NC
Practice Address - Zip Code:28097-9793
Practice Address - Country:US
Practice Address - Phone:704-888-2114
Practice Address - Fax:704-888-2125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
NC071083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0135822Medicaid
3435307OtherNCPDP PROVIDER IDENTIFICATION NUMBER
3435307OtherNCPDP PROVIDER IDENTIFICATION NUMBER