Provider Demographics
NPI:1376853515
Name:MOLL, KEVIN ALAN (RPH)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ALAN
Last Name:MOLL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1992 LANCASTER DR NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305
Mailing Address - Country:US
Mailing Address - Phone:503-362-4845
Mailing Address - Fax:
Practice Address - Street 1:1992 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305
Practice Address - Country:US
Practice Address - Phone:503-362-4845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8292183500000X
AZ9517183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist