1548581960 NPI number — MOUNTAIN COMPOUNDING

Table of content: (NPI 1548581960)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548581960 NPI number — MOUNTAIN COMPOUNDING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN COMPOUNDING
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:
Provider Other Organization Name Type Code:
6
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:
1548581960
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 SOUTH CALIFORNIA ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
MISSOULA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-541-3172
Provider Business Mailing Address Fax Number:
406-541-3173

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 S CALIFORNIA ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MISSOULA
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59801-1745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-541-3172
Provider Business Practice Location Address Fax Number:
406-541-3173
Provider Enumeration Date:
06/21/2010

Additional Information

Authorized Official

Authorized Official Last Name:
HATHEWAY
Authorized Official First Name:
GERARD
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PHARMACY
Authorized Official Telephone Number:
406-541-3172

Provider Taxonomy Codes

  • Taxonomy code: 3336C0004X , with the licence number:  1307 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2783682 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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