MEDICARE: JEAN YEUNG MOON PHARM.D.

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	117897-3	MN

General Provider Information

NPI Number	:	1851393672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEAN YEUNG MOON PHARM.D.

Provider Business Mailing Address
First Line	:	15848 50TH AVE N
Second Line	:
City	:	PLYMOUTH
State	:	MN
Zip	:	55446-3471
Country	:	US
Telephone Number	:	612-730-7212
Fax Number	:

Provider Business Practice Location Address
First Line	:	1020 W BROADWAY AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55411-2504
Country	:	US
Telephone Number	:	612-302-8361
Fax Number	:	612-302-8277

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

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	07/08/2007

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