Provider Demographics
NPI:1649670050
Name:MOLES, LORI ANN
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:MOLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 GREAT TEAYS BLVD
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9548
Mailing Address - Country:US
Mailing Address - Phone:304-757-3201
Mailing Address - Fax:304-757-1170
Practice Address - Street 1:101 GREAT TEAYS BLVD
Practice Address - Street 2:
Practice Address - City:SCOTT DEPOT
Practice Address - State:WV
Practice Address - Zip Code:25560-9548
Practice Address - Country:US
Practice Address - Phone:304-757-3201
Practice Address - Fax:304-757-1170
Is Sole Proprietor?:No
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP5589183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist