Provider Demographics
NPI:1932219888
Name:MOOSE DRUG COMPANY
Entity Type:Organization
Organization Name:MOOSE DRUG COMPANY
Other - Org Name:MOOSE DRUG COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MOOSE
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:704-436-9613
Mailing Address - Street 1:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:NC
Mailing Address - Zip Code:28124-0067
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8374 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:NC
Practice Address - Zip Code:28124-8812
Practice Address - Country:US
Practice Address - Phone:704-436-9613
Practice Address - Fax:704-436-6512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
NC053953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0135046Medicaid
3409237OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NC0135046Medicaid