Provider Demographics
NPI:1780803213
Name:MOULTON, JENNNIFER RENEE (RPH)
Entity type:Individual
Prefix:MRS
First Name:JENNNIFER
Middle Name:RENEE
Last Name:MOULTON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 CODY DR
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-6391
Mailing Address - Country:US
Mailing Address - Phone:515-267-1413
Mailing Address - Fax:515-270-2979
Practice Address - Street 1:8515 DOUGLAS AVE
Practice Address - Street 2:SUITE 16
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50322-2924
Practice Address - Country:US
Practice Address - Phone:515-270-0713
Practice Address - Fax:515-270-2979
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18248183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist