Provider Demographics
NPI:1568789949
Name:MOON, JENNIFER PRATT
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:PRATT
Last Name:MOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 E COLORADO BLVD
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-3203
Mailing Address - Country:US
Mailing Address - Phone:605-642-8749
Mailing Address - Fax:605-642-4057
Practice Address - Street 1:2323 E COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-3203
Practice Address - Country:US
Practice Address - Phone:605-642-8749
Practice Address - Fax:605-642-4057
Is Sole Proprietor?:No
Enumeration Date:2010-04-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5165183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist