Provider Demographics
NPI:1891332029
Name:MOLDOWAN, CONOR MICHAEL (RPH)
Entity Type:Individual
Prefix:
First Name:CONOR
Middle Name:MICHAEL
Last Name:MOLDOWAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 BLUCHER VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-5821
Mailing Address - Country:US
Mailing Address - Phone:707-570-9391
Mailing Address - Fax:
Practice Address - Street 1:2501 BLUCHER VALLEY RD
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-5821
Practice Address - Country:US
Practice Address - Phone:707-570-9391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPH60997865183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist