Provider Demographics
NPI:1013660299
Name:MOUILLESSEAUX, KODY
Entity Type:Individual
Prefix:
First Name:KODY
Middle Name:
Last Name:MOUILLESSEAUX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13401 INTERSTATE 10 E
Mailing Address - Street 2:
Mailing Address - City:MONT BELVIEU
Mailing Address - State:TX
Mailing Address - Zip Code:77523-1549
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13401 INTERSTATE 10 E
Practice Address - Street 2:
Practice Address - City:MONT BELVIEU
Practice Address - State:TX
Practice Address - Zip Code:77523-1549
Practice Address - Country:US
Practice Address - Phone:281-420-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician