Healthcare Provider Details

I. General information

NPI: 1013316116
Provider Name (Legal Business Name): AMANDA MOON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6110 FIRESTONE BLVD
FIRESTONE CO
80504-6425
US

IV. Provider business mailing address

6110 FIRESTONE BLVD
FIRESTONE CO
80504-6425
US

V. Phone/Fax

Practice location:
  • Phone: 303-682-4170
  • Fax:
Mailing address:
  • Phone: 303-682-4170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number24326
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number24326
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: