Provider Demographics
NPI:1518587104
Name:MOLTER, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MOLTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 E CLIFTON ST
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-2633
Mailing Address - Country:US
Mailing Address - Phone:608-372-5355
Mailing Address - Fax:
Practice Address - Street 1:701 E CLIFTON ST
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-2633
Practice Address - Country:US
Practice Address - Phone:608-372-5355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIP0018X183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist