Provider Demographics
NPI:1821378522
Name:MOON, ADAM (PHARMD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:MOON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-1907
Mailing Address - Country:US
Mailing Address - Phone:860-423-1661
Mailing Address - Fax:
Practice Address - Street 1:1213 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-1907
Practice Address - Country:US
Practice Address - Phone:860-423-1661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0010375183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist