Provider Demographics
NPI:1255700035
Name:MOE, DYLAN (PHARM D)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:MOE
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1936 LEXINGTON AVE APT A
Mailing Address - Street 2:
Mailing Address - City:GREAT LAKES
Mailing Address - State:IL
Mailing Address - Zip Code:60088-1048
Mailing Address - Country:US
Mailing Address - Phone:224-216-2249
Mailing Address - Fax:
Practice Address - Street 1:1770 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-1317
Practice Address - Country:US
Practice Address - Phone:847-327-9706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051299082183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist