Provider Demographics
NPI:1871274803
Name:MOUA, JASON (RPH)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:MOUA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 4TH ST E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-4012
Mailing Address - Country:US
Mailing Address - Phone:651-408-4855
Mailing Address - Fax:
Practice Address - Street 1:1920 BUERKLE RD
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-1300
Practice Address - Country:US
Practice Address - Phone:651-777-2350
Practice Address - Fax:651-777-2537
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN126136183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist