Provider Demographics
NPI:1558541466
Name:MOFFETT, MICHAEL EUGENE (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:EUGENE
Last Name:MOFFETT
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3615 SANGANI BLVD
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-8770
Mailing Address - Country:US
Mailing Address - Phone:228-396-4617
Mailing Address - Fax:
Practice Address - Street 1:3615 SANGANI BLVD
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-8770
Practice Address - Country:US
Practice Address - Phone:228-396-4617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-6934183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist