Provider Demographics
NPI:1891395323
Name:MOSS, KELLYE RENEE' (RPH)
Entity Type:Individual
Prefix:MISS
First Name:KELLYE
Middle Name:RENEE'
Last Name:MOSS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4081 VAL ROSE LN
Mailing Address - Street 2:
Mailing Address - City:ROYSE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:75189-2813
Mailing Address - Country:US
Mailing Address - Phone:903-413-0052
Mailing Address - Fax:
Practice Address - Street 1:802 E US HIGHWAY 80
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-8620
Practice Address - Country:US
Practice Address - Phone:972-564-9160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35863183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist