Provider Demographics
NPI:1659984532
Name:OWUSU, MOSES KWABENA
Entity Type:Individual
Prefix:
First Name:MOSES
Middle Name:KWABENA
Last Name:OWUSU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 N ALPINE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3613
Mailing Address - Country:US
Mailing Address - Phone:815-398-2443
Mailing Address - Fax:
Practice Address - Street 1:1145 N ALPINE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3613
Practice Address - Country:US
Practice Address - Phone:815-398-2443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26026015A183500000X
IL051-298198183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist