Provider Demographics
NPI:1699891937
Name:MOFFA, KENNETH JOSEPH (RPH)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:JOSEPH
Last Name:MOFFA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 CHIVAS COURT
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-3740
Mailing Address - Country:US
Mailing Address - Phone:631-283-3943
Mailing Address - Fax:
Practice Address - Street 1:81 MAIN STREET
Practice Address - Street 2:WHITES PHARMACY
Practice Address - City:EAST HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11937
Practice Address - Country:US
Practice Address - Phone:631-324-0082
Practice Address - Fax:631-324-0338
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY24002-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist