Provider Demographics
NPI:1346261575
Name:PHARMERICA MOUNTAIN LLC
Entity Type:Organization
Organization Name:PHARMERICA MOUNTAIN LLC
Other - Org Name:PHARMERICA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-630-7429
Mailing Address - Street 1:3802 CORPOREX PARK DR
Mailing Address - Street 2:STE 150
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-1125
Mailing Address - Country:US
Mailing Address - Phone:813-318-6039
Mailing Address - Fax:
Practice Address - Street 1:3825 W CHEYENNE AVE # 603
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-3408
Practice Address - Country:US
Practice Address - Phone:702-871-1920
Practice Address - Fax:702-871-4203
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHARMERICA CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-22
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPH016353336L0003X, 3336L0003X
332BP3500X, 332B00000X, 3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVPHC01635OtherBOARD OF PHARMACY
NV003702002Medicaid
UT10562714-1708OtherBOARD OF PHARMACY
UT10562714-8913OtherCONTROLLED SUBSTANCE
UT11465757-1708OtherBOARD OF PHARMACY
UT3000009Medicaid
UT11465757-8913OtherBOARD OF PHARMACY