Provider Demographics
NPI:1235727785
Name:MOULTON, DONALD ALBERT JR
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:ALBERT
Last Name:MOULTON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 303
Mailing Address - Street 2:
Mailing Address - City:LANESBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01237-0303
Mailing Address - Country:US
Mailing Address - Phone:413-447-8252
Mailing Address - Fax:
Practice Address - Street 1:660 MERRILL RD
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-2083
Practice Address - Country:US
Practice Address - Phone:413-443-0064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16607183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist