Provider Demographics
NPI:1760926547
Name:MAGNESS MOSS PHARMACY
Entity Type:Organization
Organization Name:MAGNESS MOSS PHARMACY
Other - Org Name:BLOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSSIER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:972-832-7668
Mailing Address - Street 1:PO BOX 947
Mailing Address - Street 2:
Mailing Address - City:JOAQUIN
Mailing Address - State:TX
Mailing Address - Zip Code:75954-0947
Mailing Address - Country:US
Mailing Address - Phone:936-269-3922
Mailing Address - Fax:936-269-9809
Practice Address - Street 1:13290 US HIGHWAY 84 E
Practice Address - Street 2:
Practice Address - City:JOAQUIN
Practice Address - State:TX
Practice Address - Zip Code:75954
Practice Address - Country:US
Practice Address - Phone:936-269-3922
Practice Address - Fax:936-269-9809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-13
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2205145Medicaid
TX149590Medicaid