Provider Demographics
NPI:1467704080
Name:MOSS, DOUGLAS WAYNE
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:WAYNE
Last Name:MOSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:356 WV HIGHWAY 5 E
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26351-7602
Mailing Address - Country:US
Mailing Address - Phone:304-462-8300
Mailing Address - Fax:304-462-0324
Practice Address - Street 1:356 WV HIGHWAY 5 E
Practice Address - Street 2:
Practice Address - City:GLENVILLE
Practice Address - State:WV
Practice Address - Zip Code:26351-7602
Practice Address - Country:US
Practice Address - Phone:304-462-8300
Practice Address - Fax:304-462-0324
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV183500000X183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist