MEDICARE: MOOSE PHARMACY OF MONROE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336L0003X	Long Term Care Pharmacy

General Provider Information

NPI Number	:	1316637002
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOOSE PHARMACY OF MONROE LLC

Provider Business Mailing Address
First Line	:	215 E JEFFERSON ST
Second Line	:
City	:	MONROE
State	:	NC
Zip	:	28112-4865
Country	:	US
Telephone Number	:	704-283-8131
Fax Number	:	704-289-1954

Provider Business Practice Location Address
First Line	:	215 E JEFFERSON ST
Second Line	:
City	:	MONROE
State	:	NC
Zip	:	28112-4865
Country	:	US
Telephone Number	:	704-283-8131
Fax Number	:	704-289-1954

Authorized Official
Title or Position	:	PHARMACY OWNER
Name	:	ASHLEY LYNN MOOSE
Credential	:	PHARMD
Telephone Number	:	704-283-8131

Provider Enumeration Date	:	05/08/2023
Last Update Date	:	05/08/2023

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