Provider Demographics
NPI:1114445707
Name:BUMGARDNER, CASSIDY MOSES (PHARMD)
Entity Type:Individual
Prefix:
First Name:CASSIDY
Middle Name:MOSES
Last Name:BUMGARDNER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:CASSIDY
Other - Middle Name:NICOLE
Other - Last Name:MOSES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:174 CABIN RD
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36093-1813
Mailing Address - Country:US
Mailing Address - Phone:334-514-2621
Mailing Address - Fax:
Practice Address - Street 1:215 PERRY HILL RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36109-3725
Practice Address - Country:US
Practice Address - Phone:334-233-1219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-02
Last Update Date:2017-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL20076183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist