Provider Demographics
NPI:1205479748
Name:MOULTON, WADE OLIVER (PHARM D)
Entity type:Individual
Prefix:
First Name:WADE
Middle Name:OLIVER
Last Name:MOULTON
Suffix:
Gender:M
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 1:432 W 1070 S
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-4770
Mailing Address - Country:US
Mailing Address - Phone:435-789-0250
Mailing Address - Fax:
Practice Address - Street 1:1080 W HWY 40
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078
Practice Address - Country:US
Practice Address - Phone:435-789-7235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4907684-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist