Provider Demographics
NPI:1366965576
Name:MOULTRIE PHARMACY AT LANGTOWN LLC
Entity type:Organization
Organization Name:MOULTRIE PHARMACY AT LANGTOWN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MOULTRIE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:256-566-3174
Mailing Address - Street 1:1380 OLD HIGHWAY 24
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:AL
Mailing Address - Zip Code:35673-5600
Mailing Address - Country:US
Mailing Address - Phone:256-566-3174
Mailing Address - Fax:256-350-3366
Practice Address - Street 1:20332 AL HIGHWAY 33
Practice Address - Street 2:
Practice Address - City:MOULTON
Practice Address - State:AL
Practice Address - Zip Code:35650-9204
Practice Address - Country:US
Practice Address - Phone:256-566-3174
Practice Address - Fax:256-350-3366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-19
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy