Healthcare Provider Details

I. General information

NPI: 1255760203
Provider Name (Legal Business Name): GARY MORONI PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2013
Last Update Date: 11/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19016 FORT ST
RIVERVIEW MI
48193-6701
US

IV. Provider business mailing address

19016 FORT ST
RIVERVIEW MI
48193-6701
US

V. Phone/Fax

Practice location:
  • Phone: 734-479-2010
  • Fax:
Mailing address:
  • Phone: 734-479-2010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302039792
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03132359
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: