Basic Information
| Provider Information | |||||||||
| NPI: | 1083020200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOUTON | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | PHILLIP | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARM.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2150 PENNSYLVANIA AVE NW STE G-201 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200373201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2027412218 | ||||||||
| FaxNumber: | 2027413621 | ||||||||
| Practice Location | |||||||||
| Address1: | 2150 PENNSYLVANIA AVE NW FL 4 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200373201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2027412222 | ||||||||
| FaxNumber: | 2027412185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2014 | ||||||||
| LastUpdateDate: | 04/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 22389 | MD | N | Pharmacy Service Providers | Pharmacist | 183500000X | 0202212951 | VA | N | Pharmacy Service Providers | Pharmacist | 183500000X | PH100001742 | DC | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.