Provider Demographics
NPI:1801362223
Name:MOULDER, SAMANTHA JANE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JANE
Last Name:MOULDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1419 N OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-2115
Mailing Address - Country:US
Mailing Address - Phone:208-989-0183
Mailing Address - Fax:
Practice Address - Street 1:700 12TH AVE S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-4255
Practice Address - Country:US
Practice Address - Phone:208-467-1560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCT46828183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician