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General NPI Number Information
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NPI Number | 1255106324
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Entity Type | Individual
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Provider Name | TYLER MOON
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Gender | Male
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Dates
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Enumeration Date | 11/20/2023
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Last Update Date | 11/20/2023
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Provider Practice Location Address
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Address Line | 65 NEWPORT AVE
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City | QUINCY
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State | MA
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Zip | 02171-2643
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Country | US
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Telephone | 617-328-4477
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Fax |
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Provider Business Mailing Address
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Address Line | 2124 DALEWOOD AVE
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City | FULLERTON
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State | CA
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Zip | 92833-4809
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Country | US
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Telephone | 714-800-3693
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | PH997193
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License Number State | MA
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