Provider Demographics
NPI:1992043475
Name:MOON, ANN MARIE
Entity Type:Individual
Prefix:DR
First Name:ANN
Middle Name:MARIE
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 1:3370 SUGARLOAF PKWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-5478
Mailing Address - Country:US
Mailing Address - Phone:678-376-6055
Mailing Address - Fax:678-376-6299
Practice Address - Street 1:3370 SUGARLOAF PKWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-5478
Practice Address - Country:US
Practice Address - Phone:678-376-6055
Practice Address - Fax:678-376-6299
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH022100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist