1760494033 NPI number — PHARMERICA MOUNTAIN LLC

Table of content: (NPI 1760494033)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760494033 NPI number — PHARMERICA MOUNTAIN LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHARMERICA MOUNTAIN LLC
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:
1760494033
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
805 N WHITTINGTON PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40222-7101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-627-7000
Provider Business Mailing Address Fax Number:
502-627-7401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2950 E MAGIC VIEW DR STE 190
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-887-1951
Provider Business Practice Location Address Fax Number:
208-895-9825
Provider Enumeration Date:
08/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
ALLISON
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
502-630-7429

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X , with the licence number:  1929LS , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 47154LS . This is a "BOARD OF PHARMACY" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 1704147 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6022362 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 807106500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: RP-0002900 . This is a "BOARD OF PHARMACY" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 276268 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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