Provider Demographics
NPI:1770220956
Name:MOSEMAN, CODY JAMES
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:JAMES
Last Name:MOSEMAN
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 1:2020 S LUXURY LN APT D205
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4310
Mailing Address - Country:US
Mailing Address - Phone:505-363-7107
Mailing Address - Fax:
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-381-2490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID81511481835P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0200XPharmacy Service ProvidersPharmacistPediatrics