Provider Demographics
NPI:1174857155
Name:MULDER, LACY ANN (RPH)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:ANN
Last Name:MULDER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 W LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13452-1218
Mailing Address - Country:US
Mailing Address - Phone:518-222-1189
Mailing Address - Fax:
Practice Address - Street 1:101 SANFORD FARMS SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-7535
Practice Address - Country:US
Practice Address - Phone:518-843-6895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-24
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053973-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist