Provider Demographics
NPI:1841941093
Name:MOULTRIE PHARMACY AT CADDO LLC
Entity type:Organization
Organization Name:MOULTRIE PHARMACY AT CADDO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MOULTRIE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:256-566-3174
Mailing Address - Street 1:22747 AL HIGHWAY 24 STE D
Mailing Address - Street 2:
Mailing Address - City:MOULTON
Mailing Address - State:AL
Mailing Address - Zip Code:35650-8102
Mailing Address - Country:US
Mailing Address - Phone:256-905-0030
Mailing Address - Fax:256-905-0049
Practice Address - Street 1:22747 AL HIGHWAY 24 STE D
Practice Address - Street 2:
Practice Address - City:MOULTON
Practice Address - State:AL
Practice Address - Zip Code:35650-8102
Practice Address - Country:US
Practice Address - Phone:256-905-0030
Practice Address - Fax:256-905-0049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy