Provider Demographics
NPI:1992196299
Name:MOULTON, AMANDA (PHARM, D)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:MOULTON
Suffix:
Gender:F
Credentials:PHARM, D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3850 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-1045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3850 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1045
Practice Address - Country:US
Practice Address - Phone:334-794-6112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14335183500000X
GA23513183500000X
FL42288183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist