Provider Demographics
NPI:1629228358
Name:MOSS, CHARLES S (RPH)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:MOSS
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 1:11 COUNTY ROAD 676
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-7419
Mailing Address - Country:US
Mailing Address - Phone:662-223-9015
Mailing Address - Fax:
Practice Address - Street 1:409 MULBERRY AVE
Practice Address - Street 2:
Practice Address - City:SELMER
Practice Address - State:TN
Practice Address - Zip Code:38375-2307
Practice Address - Country:US
Practice Address - Phone:731-645-4423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11120183500000X
MST08597183500000X
AL12812183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist