Provider Demographics
NPI:1467464925
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:
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 STE 150
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-1135
Mailing Address - Country:US
Mailing Address - Phone:813-318-6039
Mailing Address - Fax:800-825-6408
Practice Address - Street 1:3700 E COLUMBIA ST
Practice Address - Street 2:SUITE 100
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85714
Practice Address - Country:US
Practice Address - Phone:800-252-6721
Practice Address - Fax:800-282-6729
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHARMERICA CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-13
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42033336L0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300012682Medicaid
AZY007461OtherBOARD OF PHARMACY
AZ920208Medicaid