Provider Demographics
NPI:1063011450
Name:MOON, SUSAN S (PHARMD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:S
Last Name:MOON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 LIBERTY ST APT 1311
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-5839
Mailing Address - Country:US
Mailing Address - Phone:248-556-6810
Mailing Address - Fax:
Practice Address - Street 1:2728 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-5117
Practice Address - Country:US
Practice Address - Phone:937-525-6770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-18
Last Update Date:2020-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03439383183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist