Provider Demographics
NPI:1033495593
Name:MOSS, MICHELLE D (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:D
Last Name:MOSS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:D
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:VINITA
Mailing Address - State:OK
Mailing Address - Zip Code:74301-0069
Mailing Address - Country:US
Mailing Address - Phone:918-713-5541
Mailing Address - Fax:918-256-6490
Practice Address - Street 1:24800 S 4420 RD
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301-5544
Practice Address - Country:US
Practice Address - Phone:918-713-5541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-28
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12852183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist