Healthcare Provider Details

I. General information

NPI: 1891153979
Provider Name (Legal Business Name): MICHELLE MOON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2016
Last Update Date: 02/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43839 15TH ST W
LANCASTER CA
93534-4756
US

IV. Provider business mailing address

13261 DROXFORD ST
CERRITOS CA
90703-6257
US

V. Phone/Fax

Practice location:
  • Phone: 661-945-5984
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number69713
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: