Provider Demographics
NPI:1598836249
Name:MOSS, THOMAS EDWARD III (RPH)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:EDWARD
Last Name:MOSS
Suffix:III
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 1:1804 59TH ST. WEST
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-4616
Mailing Address - Country:US
Mailing Address - Phone:941-792-2688
Mailing Address - Fax:941-794-6156
Practice Address - Street 1:1804 59TH ST. WEST
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4616
Practice Address - Country:US
Practice Address - Phone:941-792-2688
Practice Address - Fax:941-794-6156
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL12690183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFL12690OtherPHARMACY LICENSE