Provider Demographics
NPI:1720778442
Name:MOOSE PHARMACY OF MT HOLLY LLC
Entity Type:Organization
Organization Name:MOOSE PHARMACY OF MT HOLLY LLC
Other - Org Name:MOOSE PHARMACY OF MOUNT HOLLY LONG-TERM CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRIST
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:704-827-2211
Mailing Address - Street 1:125 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NC
Mailing Address - Zip Code:28120-1616
Mailing Address - Country:US
Mailing Address - Phone:704-827-2211
Mailing Address - Fax:704-827-7134
Practice Address - Street 1:125 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NC
Practice Address - Zip Code:28120-1616
Practice Address - Country:US
Practice Address - Phone:704-827-2211
Practice Address - Fax:704-827-7134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-08
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy