Provider Demographics
NPI:1811971351
Name:MOLLIEN, CHARLES THOMAS (PHARMD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:THOMAS
Last Name:MOLLIEN
Suffix:
Gender:M
Credentials:PHARMD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1231 E BELTLINE AVE NE
Mailing Address - Street 2:MAIL STOP 1260
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-4501
Mailing Address - Country:US
Mailing Address - Phone:616-464-8045
Mailing Address - Fax:877-974-4411
Practice Address - Street 1:1231 E BELTLINE AVE NE
Practice Address - Street 2:MAIL STOP 1260
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-4501
Practice Address - Country:US
Practice Address - Phone:616-464-8045
Practice Address - Fax:877-974-4411
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL051292340183500000X
MI5302033601183500000X
AZS15027183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist