MEDICARE: MOON LAKE PHARMACY

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	3336C0003X	Community/Retail Pharmacy	PH 22873	FL

General Provider Information

NPI Number	:	1053500066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOON LAKE PHARMACY

Provider Business Mailing Address
First Line	:	9111 RIDGE RD
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34654-5059
Country	:	US
Telephone Number	:	727-846-1800
Fax Number	:	727-846-1822

Provider Business Practice Location Address
First Line	:	9111 RIDGE RD
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34654-5059
Country	:	US
Telephone Number	:	727-846-1800
Fax Number	:	727-846-1822

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. VIVIAN ALBERTO
Credential	:
Telephone Number	:	727-846-1800

Provider Enumeration Date	:	10/16/2007
Last Update Date	:	10/16/2007

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Directions to “MOON LAKE PHARMACY ” Practice Location

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