Provider Demographics
NPI:1013356112
Name:MOUNTAIN CARE PHARMACY HOUSTON LLC
Entity Type:Organization
Organization Name:MOUNTAIN CARE PHARMACY HOUSTON LLC
Other - Org Name:MOUNTAIN CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:MEMMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-713-0106
Mailing Address - Street 1:1030 W BELLWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-4494
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10665 RICHMOND AVE STE 195
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042-5110
Practice Address - Country:US
Practice Address - Phone:713-300-0191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-21
Last Update Date:2013-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336C0004X
TX287223336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2141042OtherPK