Provider Demographics
NPI:1902404858
Name:MOSLEY, ANGELA LEE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:LEE
Last Name:MOSLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W9009 BUCKHORN RD
Mailing Address - Street 2:
Mailing Address - City:BROWNTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53522-9767
Mailing Address - Country:US
Mailing Address - Phone:608-558-7747
Mailing Address - Fax:
Practice Address - Street 1:2545 IL ROUTE 26 S
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-9370
Practice Address - Country:US
Practice Address - Phone:815-232-8141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051290541183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist