Provider Demographics
NPI:1932270295
Name:MOOSE, KRIS E (RPH)
Entity Type:Individual
Prefix:MR
First Name:KRIS
Middle Name:E
Last Name:MOOSE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 BROAD ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-1838
Mailing Address - Country:US
Mailing Address - Phone:304-872-9000
Mailing Address - Fax:304-872-4419
Practice Address - Street 1:1129 BROAD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-1838
Practice Address - Country:US
Practice Address - Phone:304-872-9000
Practice Address - Fax:304-872-4419
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0005845183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVRP0005845OtherPHARMACIST LICENSE