Provider Demographics
NPI:1922118769
Name:MOON'S PHARMACY LTC
Entity Type:Organization
Organization Name:MOON'S PHARMACY LTC
Other - Org Name:MOON'S PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:229-382-3711
Mailing Address - Street 1:717 B W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794
Mailing Address - Country:US
Mailing Address - Phone:229-382-3711
Mailing Address - Fax:229-387-7521
Practice Address - Street 1:711 2ND ST W
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-4201
Practice Address - Country:US
Practice Address - Phone:229-256-0139
Practice Address - Fax:229-256-0140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0088773336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00003855CMedicaid
1152482OtherNDCP