Provider Demographics
NPI:1760549331
Name:MULDOON, JOHN RICHARD
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RICHARD
Last Name:MULDOON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:
Other - Last Name:MULDOON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BS
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:MARSING
Mailing Address - State:ID
Mailing Address - Zip Code:83639-0037
Mailing Address - Country:US
Mailing Address - Phone:208-896-4220
Mailing Address - Fax:
Practice Address - Street 1:106 S COLE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709
Practice Address - Country:US
Practice Address - Phone:208-376-6810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP2940183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist