Provider Demographics
NPI:1942816236
Name:MOFFETT, PHILIP PATRICK (PHARMD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:PATRICK
Last Name:MOFFETT
Suffix:
Gender:M
Credentials:PHARMD
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 436
Mailing Address - Street 2:
Mailing Address - City:POLACCA
Mailing Address - State:AZ
Mailing Address - Zip Code:86042-0436
Mailing Address - Country:US
Mailing Address - Phone:208-313-4904
Mailing Address - Fax:
Practice Address - Street 1:HIGHWAY 264 MILE MARKER 388
Practice Address - Street 2:
Practice Address - City:POLACCA
Practice Address - State:AZ
Practice Address - Zip Code:86042
Practice Address - Country:US
Practice Address - Phone:928-737-6000
Practice Address - Fax:928-737-6332
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP8525183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist