Provider Demographics
NPI:1639463581
Name:MOSS, BRADLEY L
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:L
Last Name:MOSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BRADLEY
Other - Middle Name:L
Other - Last Name:MOSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:2221 CLOVERDALE AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2301
Mailing Address - Country:US
Mailing Address - Phone:336-723-4365
Mailing Address - Fax:336-724-9674
Practice Address - Street 1:2221 CLOVERDALE AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2301
Practice Address - Country:US
Practice Address - Phone:336-723-4365
Practice Address - Fax:336-724-9674
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7827183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist