Provider Demographics
NPI:1659866762
Name:HENDERSON, MOSES TJ (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MOSES
Middle Name:TJ
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 1ST AVE APT B113
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-7592
Mailing Address - Country:US
Mailing Address - Phone:859-979-1006
Mailing Address - Fax:
Practice Address - Street 1:710 CENTER ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1527
Practice Address - Country:US
Practice Address - Phone:706-571-1495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-30
Last Update Date:2018-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH030586183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist