1336228006 NPI number — MOUNTAIN LAKE PHARMACY INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336228006 NPI number — MOUNTAIN LAKE PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN LAKE PHARMACY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MOUNTAIN LAKE PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336228006
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1129 BROAD ST
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
SUMMERSVILLE
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26651-1838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-872-9000
Provider Business Mailing Address Fax Number:
304-872-4419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1129 BROAD ST
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
SUMMERSVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26651-1838
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-872-9000
Provider Business Practice Location Address Fax Number:
304-872-4419
Provider Enumeration Date:
11/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOONE
Authorized Official First Name:
HOWARD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT PIC
Authorized Official Telephone Number:
304-872-9000

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: SP0552314 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6001398000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5054046 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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