Provider Demographics
NPI:1700149754
Name:MOUA, KOR
Entity Type:Individual
Prefix:
First Name:KOR
Middle Name:
Last Name:MOUA
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 1:44 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-7815
Mailing Address - Country:US
Mailing Address - Phone:978-870-5502
Mailing Address - Fax:
Practice Address - Street 1:140 WHALON ST
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-7158
Practice Address - Country:US
Practice Address - Phone:978-345-7540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-23
Last Update Date:2012-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH233710183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist