Provider Demographics
NPI:1710587589
Name:MOLLERSTROM, MARTHA (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:MOLLERSTROM
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 1:8315 FM 78
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-1043
Mailing Address - Country:US
Mailing Address - Phone:210-666-6507
Mailing Address - Fax:210-666-6524
Practice Address - Street 1:8315 FM 78
Practice Address - Street 2:
Practice Address - City:CONVERSE
Practice Address - State:TX
Practice Address - Zip Code:78109-1043
Practice Address - Country:US
Practice Address - Phone:210-666-6507
Practice Address - Fax:210-666-6524
Is Sole Proprietor?:No
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX43837183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist