Provider Demographics
NPI:1235488388
Name:MOES RX CLINIC INC
Entity Type:Organization
Organization Name:MOES RX CLINIC INC
Other - Org Name:MOE'S RX CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:MOHSEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHORDEHFOROSH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:704-910-1242
Mailing Address - Street 1:1711 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-5107
Mailing Address - Country:US
Mailing Address - Phone:704-910-1242
Mailing Address - Fax:704-910-1350
Practice Address - Street 1:1711 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-5107
Practice Address - Country:US
Practice Address - Phone:704-910-1242
Practice Address - Fax:704-910-1350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-05
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11351333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2136744OtherPK