MEDICARE: MS. KIMBERLY MOON PHARMD

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	183500000X	Pharmacist	5302036487	MI

General Provider Information

NPI Number	:	1568620631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KIMBERLY MOON PHARMD

Provider Business Mailing Address
First Line	:	600 E LAFAYETTE BLVD
Second Line	:	MAIL CODE 1705
City	:	DETROIT
State	:	MI
Zip	:	48226-2927
Country	:	US
Telephone Number	:	313-225-7641
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 E LAFAYETTE BLVD
Second Line	:	MAIL CODE 1705
City	:	DETROIT
State	:	MI
Zip	:	48226-2927
Country	:	US
Telephone Number	:	313-225-7641
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2008
Last Update Date	:	09/20/2012

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