Provider Demographics
NPI:1225707276
Name:NIMO, MOSES (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:MOSES
Middle Name:
Last Name:NIMO
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4414 W MADISON PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-8542
Mailing Address - Country:US
Mailing Address - Phone:918-406-0826
Mailing Address - Fax:
Practice Address - Street 1:5046 S SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-5714
Practice Address - Country:US
Practice Address - Phone:918-627-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-12
Last Update Date:2021-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19381183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist