Provider Demographics
NPI:1215337498
Name:MOON, ALYSSA M (PHARMD)
Entity type:Individual
Prefix:MISS
First Name:ALYSSA
Middle Name:M
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 1:3485 PROMENADE PL APT 203
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-7282
Mailing Address - Country:US
Mailing Address - Phone:724-554-9691
Mailing Address - Fax:
Practice Address - Street 1:11906 LIVINGSTON RD
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-4286
Practice Address - Country:US
Practice Address - Phone:724-554-9691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-25
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22560183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist