Provider Demographics
NPI:1942811674
Name:MOSES, EVAN S
Entity Type:Individual
Prefix:MR
First Name:EVAN
Middle Name:S
Last Name:MOSES
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 1:58 FRIEND ST APT 1
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-3291
Mailing Address - Country:US
Mailing Address - Phone:978-412-5749
Mailing Address - Fax:
Practice Address - Street 1:174 MAIN ST
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-5644
Practice Address - Country:US
Practice Address - Phone:978-977-4844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-15
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPT24422183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Single Specialty