Provider Demographics
NPI:1093052276
Name:MOON, GLADYS B (RPH)
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:B
Last Name:MOON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6551 N ORANGE BLOSSOM TRL
Mailing Address - Street 2:SUITE 155
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-7013
Mailing Address - Country:US
Mailing Address - Phone:352-383-2352
Mailing Address - Fax:352-383-5432
Practice Address - Street 1:6551 N ORANGE BLOSSOM TRL
Practice Address - Street 2:SUITE 155
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-7013
Practice Address - Country:US
Practice Address - Phone:352-383-2352
Practice Address - Fax:352-383-5432
Is Sole Proprietor?:No
Enumeration Date:2013-01-08
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS12895183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist