Provider Demographics
NPI:1760812002
Name:MOSHER, CASEY
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:
Last Name:MOSHER
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 1:5500 CLYDE PARK AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-9525
Mailing Address - Country:US
Mailing Address - Phone:616-531-9629
Mailing Address - Fax:616-530-7165
Practice Address - Street 1:5500 CLYDE PARK AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-9525
Practice Address - Country:US
Practice Address - Phone:616-531-9629
Practice Address - Fax:616-530-7165
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-23
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302036229183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist