1992788962 NPI number — MR. EDWARD THOMAS MOLDENHAUER RPH (MS BPHARM)

Table of content: MR. EDWARD THOMAS MOLDENHAUER RPH (MS BPHARM) (NPI 1992788962)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992788962 NPI number — MR. EDWARD THOMAS MOLDENHAUER RPH (MS BPHARM)

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOLDENHAUER
Provider First Name:
EDWARD
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RPH (MS BPHARM)
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOLDENHAUER
Provider Other First Name:
EDWARD
Provider Other Middle Name:
THOMAS
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
JR.
Provider Other Credential Text:
RPH (MS BPHARM)
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1992788962
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 ANNIE GEORGE DR
Provider Second Line Business Mailing Address:
PO BOX 3559
Provider Business Mailing Address City Name:
MASHANTUCKET
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06338-3559
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-396-2058
Provider Business Mailing Address Fax Number:
860-396-6212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ROUTE 12 BLDG 449
Provider Second Line Business Practice Location Address:
NAVAL AMBULATORY CARE CENTER ATTN PROFESSIONAL AFFAIRS
Provider Business Practice Location Address City Name:
GROTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06349-5600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-694-2377
Provider Business Practice Location Address Fax Number:
860-694-2590
Provider Enumeration Date:
11/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1835P1200X , with the licence number:  28RI02090700 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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