Provider Demographics
NPI:1699075382
Name:MOULDS, JENNY KAY
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:KAY
Last Name:MOULDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S GREENVILLE WEST DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-3500
Mailing Address - Country:US
Mailing Address - Phone:616-754-1875
Mailing Address - Fax:616-754-1705
Practice Address - Street 1:205 SOUTH GREENVILLE DR. W
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838
Practice Address - Country:US
Practice Address - Phone:616-754-1875
Practice Address - Fax:616-754-1705
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302029838183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist