Healthcare Provider Details

I. General information

NPI: 1477848109
Provider Name (Legal Business Name): STEPHANIE MOY PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2011
Last Update Date: 06/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2112 W PETERSON AVE T2079
CHICAGO IL
60659-4277
US

IV. Provider business mailing address

2112 W PETERSON AVE T2079
CHICAGO IL
60659-4277
US

V. Phone/Fax

Practice location:
  • Phone: 773-761-3006
  • Fax: 773-761-3413
Mailing address:
  • Phone: 773-761-3006
  • Fax: 773-761-3413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.294584
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: