Provider Demographics
NPI:1497182786
Name:NELSON, MOLLY (PHARMD)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 W ESSEX ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-1928
Mailing Address - Country:US
Mailing Address - Phone:612-790-1734
Mailing Address - Fax:
Practice Address - Street 1:1801 W 11TH ST
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3727
Practice Address - Country:US
Practice Address - Phone:209-830-2955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-01
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69726183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist