Provider Demographics
NPI:1255686093
Name:MOEN, ALYSSA JO (PHARMD)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:JO
Last Name:MOEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3883 74TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:FORT TOTTEN
Mailing Address - State:ND
Mailing Address - Zip Code:58335
Mailing Address - Country:US
Mailing Address - Phone:701-766-1612
Mailing Address - Fax:701-766-1625
Practice Address - Street 1:3883 74TH AVE NE
Practice Address - Street 2:
Practice Address - City:FORT TOTTEN
Practice Address - State:ND
Practice Address - Zip Code:58335
Practice Address - Country:US
Practice Address - Phone:701-766-1612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118800183500000X
NDRPH5025183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist