Provider Demographics
NPI:1891756185
Name:MOSSMAN, JAKE (RPH)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:MOSSMAN
Suffix:
Gender:M
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:PO BOX 942
Mailing Address - Street 2:
Mailing Address - City:EL PRADO
Mailing Address - State:NM
Mailing Address - Zip Code:87529-0942
Mailing Address - Country:US
Mailing Address - Phone:505-758-8336
Mailing Address - Fax:
Practice Address - Street 1:622 PASEO DEL PUEBLO SUR
Practice Address - Street 2:5401 NDCBU
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-5101
Practice Address - Country:US
Practice Address - Phone:505-758-3342
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4584183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist