Provider Demographics
NPI:1437648334
Name:MOOSE PHARMACY OF MT HOLLY LLC
Entity Type:Organization
Organization Name:MOOSE PHARMACY OF MT HOLLY LLC
Other - Org Name:MOOSE PHARMACY OF MT. HOLLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:YODER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:704-827-2211
Mailing Address - Street 1:125 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NC
Mailing Address - Zip Code:28120-1616
Mailing Address - Country:US
Mailing Address - Phone:704-827-2211
Mailing Address - Fax:704-827-7134
Practice Address - Street 1:125 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NC
Practice Address - Zip Code:28120
Practice Address - Country:US
Practice Address - Phone:704-827-2211
Practice Address - Fax:704-827-7134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-07
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
NC137463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2177554OtherPK
NCPENDINGMedicaid