Provider Demographics
NPI:1710062948
Name:MOSHEIM PHARMACY INC
Entity Type:Organization
Organization Name:MOSHEIM PHARMACY INC
Other - Org Name:MOSHEIM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:SUSONG
Authorized Official - Suffix:
Authorized Official - Credentials:PHRMD
Authorized Official - Phone:423-639-8631
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:MOSHEIM
Mailing Address - State:TN
Mailing Address - Zip Code:37818-0100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6766 W JOHNSON HWY
Practice Address - Street 2:
Practice Address - City:MOSHEIM
Practice Address - State:TN
Practice Address - Zip Code:37818
Practice Address - Country:US
Practice Address - Phone:423-422-9099
Practice Address - Fax:423-422-9760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN29263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4428163OtherNCPDP PROVIDER IDENTIFICATION NUMBER