Provider Demographics
NPI:1669626164
Name:MOOSE PHARMACY OF SALISBURY LLC
Entity Type:Organization
Organization Name:MOOSE PHARMACY OF SALISBURY LLC
Other - Org Name:MOOSE PHARMACY OF SALISBURY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:YODER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:704-636-6340
Mailing Address - Street 1:1408 W INNES ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-2502
Mailing Address - Country:US
Mailing Address - Phone:704-636-6340
Mailing Address - Fax:704-636-6340
Practice Address - Street 1:1408 W INNES ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2502
Practice Address - Country:US
Practice Address - Phone:704-636-6340
Practice Address - Fax:704-647-0917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-11
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
NC101743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7701294Medicaid
3412587OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NC080-5530Medicaid
NC2800053Medicare PIN
NC6335940001Medicare NSC