| Entity Name: | MD MOULTON LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 08 Mar 2012 (13 years ago) |
| Date of dissolution: | 28 Sep 2018 (6 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 28 Sep 2018 (6 years ago) |
| Document Number: | L12000033363 |
| FEI/EIN Number | 45-4931044 |
| Address: | 8400 ASTRONAUT BLVD, CAPE CANAVERAL, FL, 32920, US |
| Mail Address: | 8400 Astronaut Blvd, CAPE CANAVERAL, FL, 32920, US |
| ZIP code: | 32920 |
| County: | Brevard |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1336498377 | 2012-09-06 | 2013-02-12 | 8400 ASTRONAUT BLVD, CAPE CANAVERAL, FL, 329204302, US | 8400 ASTRONAUT BLVD, CAPE CANAVERAL, FL, 329204302, US | |||||||||||||||||||||||||||||||||
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| Phone | +1 321-783-7883 |
| Fax | 3217837889 |
Authorized person
| Name | MICHAEL MOULTON |
| Role | OWNER/PHARMACIST |
| Phone | 3217837883 |
Taxonomy
| Taxonomy Code | 333600000X - Pharmacy |
| Is Primary | No |
| Taxonomy Code | 3336C0003X - Community/Retail Pharmacy |
| License Number | PH26299 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 006742800 |
| State | FL |
| Issuer | NCPDP PROVIDER IDENTIFICATION NUMBER |
| Number | 5711660 |
| Name | Role | Address |
|---|---|---|
| MOULTON MICHAEL | Agent | 8400 ASTRONAUT BLVD, CAPE CANAVERAL, FL, 32920 |
| Name | Role | Address |
|---|---|---|
| MOULTON MICHAEL | Managing Member | 8400 ASTRONAUT BLVD, CAPE CANAVERAL, FL, 32920 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G12000037652 | MIKE'S PHARMACY | EXPIRED | 2012-04-19 | 2017-12-31 | No data | 514 JEFFERSON AVE APT B, CAPE CANAVERAL, FL, 32920 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2018-09-28 | No data | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2015-01-07 | 8400 ASTRONAUT BLVD, CAPE CANAVERAL, FL 32920 | No data |
| CHANGE OF MAILING ADDRESS | 2013-04-26 | 8400 ASTRONAUT BLVD, CAPE CANAVERAL, FL 32920 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2017-01-07 |
| ANNUAL REPORT | 2016-01-28 |
| ANNUAL REPORT | 2015-01-07 |
| ANNUAL REPORT | 2014-02-04 |
| ANNUAL REPORT | 2013-04-26 |
| Florida Limited Liability | 2012-03-08 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
