Provider Demographics
NPI:1265729057
Name:MOON, RAY C (RPH)
Entity type:Individual
Prefix:MR
First Name:RAY
Middle Name:C
Last Name:MOON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1913 ADDISON AVE E
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5305
Mailing Address - Country:US
Mailing Address - Phone:208-734-4581
Mailing Address - Fax:208-736-7144
Practice Address - Street 1:1913 ADDISON AVE E
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5305
Practice Address - Country:US
Practice Address - Phone:208-734-4581
Practice Address - Fax:208-736-7144
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4261183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist