MEDICARE: MRS. JENNNIFER RENEE MOULTON RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	18248	IA

General Provider Information

NPI Number	:	1780803213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNNIFER RENEE MOULTON RPH

Provider Business Mailing Address
First Line	:	5500 CODY DR
Second Line	:
City	:	WEST DES MOINES
State	:	IA
Zip	:	50266-6391
Country	:	US
Telephone Number	:	515-267-1413
Fax Number	:	515-270-2979

Provider Business Practice Location Address
First Line	:	8515 DOUGLAS AVE
Second Line	:	SUITE 16
City	:	DES MOINES
State	:	IA
Zip	:	50322-2924
Country	:	US
Telephone Number	:	515-270-0713
Fax Number	:	515-270-2979

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	07/08/2007

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