Provider Demographics
NPI:1164024840
Name:MOSS, ANN CHILDERS
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:CHILDERS
Last Name:MOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 BRIDGEVIEW DR SE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-8472
Mailing Address - Country:US
Mailing Address - Phone:706-331-0815
Mailing Address - Fax:706-292-0647
Practice Address - Street 1:4450 ROCKMART RD SE
Practice Address - Street 2:
Practice Address - City:SILVER CREEK
Practice Address - State:GA
Practice Address - Zip Code:30173-2438
Practice Address - Country:US
Practice Address - Phone:706-292-0106
Practice Address - Fax:706-292-0647
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017632183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist