Provider Demographics
NPI:1861552887
Name:MOSLEY, JAY (RPH)
Entity type:Individual
Prefix:MR
First Name:JAY
Middle Name:
Last Name:MOSLEY
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 1:276 COLLINS ST
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:GA
Mailing Address - Zip Code:30436-4703
Mailing Address - Country:US
Mailing Address - Phone:912-526-8637
Mailing Address - Fax:912-526-0248
Practice Address - Street 1:160 S VICTORY DR
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:GA
Practice Address - Zip Code:30436-1444
Practice Address - Country:US
Practice Address - Phone:912-526-8531
Practice Address - Fax:912-526-0248
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12609183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA12609OtherSTATE LICENSE #
GA1111525OtherNABP #