Provider Demographics
NPI:1992788962
Name:MOLDENHAUER, EDWARD THOMAS (RPH (MS BPHARM))
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:THOMAS
Last Name:MOLDENHAUER
Suffix:
Gender:M
Credentials:RPH (MS BPHARM)
Other - Prefix:MR
Other - First Name:EDWARD
Other - Middle Name:THOMAS
Other - Last Name:MOLDENHAUER
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:RPH (MS BPHARM)
Mailing Address - Street 1:1 ANNIE GEORGE DR
Mailing Address - Street 2:PO BOX 3559
Mailing Address - City:MASHANTUCKET
Mailing Address - State:CT
Mailing Address - Zip Code:06338-3559
Mailing Address - Country:US
Mailing Address - Phone:860-396-2058
Mailing Address - Fax:860-396-6212
Practice Address - Street 1:ROUTE 12 BLDG 449
Practice Address - Street 2:NAVAL AMBULATORY CARE CENTER ATTN PROFESSIONAL AFFAIRS
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349-5600
Practice Address - Country:US
Practice Address - Phone:860-694-2377
Practice Address - Fax:860-694-2590
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI020907001835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy