MEDICARE: MOON LAKE PHARMACY, INC.

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	333600000X	Pharmacy		IL

General Provider Information

NPI Number	:	1841293719
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOON LAKE PHARMACY, INC.

Provider Business Mailing Address
First Line	:	1399 W SCHAUMBURG RD
Second Line	:
City	:	SCHAUMBURG
State	:	IL
Zip	:	60194-4134
Country	:	US
Telephone Number	:	847-895-3900
Fax Number	:

Provider Business Practice Location Address
First Line	:	1399 W SCHAUMBURG RD
Second Line	:
City	:	SCHAUMBURG
State	:	IL
Zip	:	60194-4134
Country	:	US
Telephone Number	:	847-895-3900
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MARC YANOW
Credential	:	R.PH.
Telephone Number	:	847-895-3900

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	08/22/2020

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