Provider Demographics
NPI:1376099358
Name:MOULTON, CHAD JOSEPH (PHARMD)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:JOSEPH
Last Name:MOULTON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 HATTON AVE
Mailing Address - Street 2:APARTMENT 205
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-6812
Mailing Address - Country:US
Mailing Address - Phone:603-531-1712
Mailing Address - Fax:
Practice Address - Street 1:5807 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97478-6961
Practice Address - Country:US
Practice Address - Phone:541-726-8423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0015538183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist