Provider Demographics
NPI:1417980509
Name:MOULTONS SPECTACLE SHOPPE
Entity Type:Organization
Organization Name:MOULTONS SPECTACLE SHOPPE
Other - Org Name:SAME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOULTON
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:413-662-2151
Mailing Address - Street 1:115 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH ADAMS
Mailing Address - State:MA
Mailing Address - Zip Code:01247-3409
Mailing Address - Country:US
Mailing Address - Phone:413-662-2151
Mailing Address - Fax:413-664-3283
Practice Address - Street 1:115 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH ADAMS
Practice Address - State:MA
Practice Address - Zip Code:01247-3409
Practice Address - Country:US
Practice Address - Phone:413-662-2151
Practice Address - Fax:413-664-3283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5319156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA=========Medicare ID - Type Unspecified