Provider Demographics
NPI:1699906644
Name:MOUTON, STEPHEN JOSEPH (PHARMD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JOSEPH
Last Name:MOUTON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1970 N COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-2093
Mailing Address - Country:US
Mailing Address - Phone:478-453-8399
Mailing Address - Fax:478-452-0732
Practice Address - Street 1:1970 N COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2093
Practice Address - Country:US
Practice Address - Phone:478-453-8399
Practice Address - Fax:478-452-0732
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA024381183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist