Provider Demographics
NPI:1174614911
Name:MOULTON, MICHAEL WEBB (RPH)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WEBB
Last Name:MOULTON
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 1:9600 BELLA DR
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-6254
Mailing Address - Country:US
Mailing Address - Phone:251-990-7988
Mailing Address - Fax:
Practice Address - Street 1:300 FAULKNER DR
Practice Address - Street 2:
Practice Address - City:BAY MINETTE
Practice Address - State:AL
Practice Address - Zip Code:36507-2771
Practice Address - Country:US
Practice Address - Phone:251-937-9746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11699183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist