Provider Demographics
NPI:1336498377
Name:MD MOULTON LLC
Entity Type:Organization
Organization Name:MD MOULTON LLC
Other - Org Name:MIKE'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MOULTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-783-7883
Mailing Address - Street 1:8400 ASTRONAUT BLVD
Mailing Address - Street 2:
Mailing Address - City:CAPE CANAVERAL
Mailing Address - State:FL
Mailing Address - Zip Code:32920-4302
Mailing Address - Country:US
Mailing Address - Phone:321-783-7883
Mailing Address - Fax:321-783-7889
Practice Address - Street 1:8400 ASTRONAUT BLVD
Practice Address - Street 2:
Practice Address - City:CAPE CANAVERAL
Practice Address - State:FL
Practice Address - Zip Code:32920-4302
Practice Address - Country:US
Practice Address - Phone:321-783-7883
Practice Address - Fax:321-783-7889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-06
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH262993336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006742800Medicaid
5711660OtherNCPDP PROVIDER IDENTIFICATION NUMBER