Provider Demographics
NPI:1114170784
Name:MOSES, ELLEN SUE (RPH)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:SUE
Last Name:MOSES
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 NATCHAUG DR
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-1913
Mailing Address - Country:US
Mailing Address - Phone:860-643-9663
Mailing Address - Fax:
Practice Address - Street 1:79 NATCHAUG DR
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-1913
Practice Address - Country:US
Practice Address - Phone:860-643-9663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8506183500000X
NM4537183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist