MEDICARE: DR. CHARLES THOMAS MOLLIEN PHARM.D.

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	051292340	IL
2	183500000X	Pharmacist	5302033601	MI
3	183500000X	Pharmacist	S15027	AZ

General Provider Information

NPI Number	:	1811971351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES THOMAS MOLLIEN PHARM.D.

Provider Business Mailing Address
First Line	:	1231 E BELTLINE AVE NE
Second Line	:	MAIL STOP 1260
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-4501
Country	:	US
Telephone Number	:	616-464-8045
Fax Number	:	877-974-4411

Provider Business Practice Location Address
First Line	:	1231 E BELTLINE AVE NE
Second Line	:	MAIL STOP 1260
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-4501
Country	:	US
Telephone Number	:	616-464-8045
Fax Number	:	877-974-4411

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

Provider Enumeration Date	:	11/29/2005
Last Update Date	:	12/30/2011

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Directions to “ DR. CHARLES THOMAS MOLLIEN PHARM.D.” Practice Location

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