Provider Demographics
NPI:1013316116
Name:MOON, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
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 1:6110 FIRESTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:FIRESTONE
Mailing Address - State:CO
Mailing Address - Zip Code:80504-6425
Mailing Address - Country:US
Mailing Address - Phone:303-682-4170
Mailing Address - Fax:
Practice Address - Street 1:6110 FIRESTONE BLVD
Practice Address - Street 2:
Practice Address - City:FIRESTONE
Practice Address - State:CO
Practice Address - Zip Code:80504-6425
Practice Address - Country:US
Practice Address - Phone:303-682-4170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO243263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy