Provider Demographics
NPI:1306290069
Name:MOULTRIE, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MOULTRIE
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 1:12182 HIGHWAY 92
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-4885
Mailing Address - Country:US
Mailing Address - Phone:770-591-9402
Mailing Address - Fax:
Practice Address - Street 1:12182 HIGHWAY 92
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-4885
Practice Address - Country:US
Practice Address - Phone:770-591-9402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHTC014196183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician