Provider Demographics
NPI:1548581960
Name:MOUNTAIN COMPOUNDING
Entity Type:Organization
Organization Name:MOUNTAIN COMPOUNDING
Other - Org Name:MOUNTAIN COMPOUNDING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:
Authorized Official - Last Name:HATHEWAY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:406-541-3172
Mailing Address - Street 1:10 SOUTH CALIFORNIA ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801
Mailing Address - Country:US
Mailing Address - Phone:406-541-3172
Mailing Address - Fax:406-541-3173
Practice Address - Street 1:101 S CALIFORNIA ST
Practice Address - Street 2:SUITE A
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-1745
Practice Address - Country:US
Practice Address - Phone:406-541-3172
Practice Address - Fax:406-541-3173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-21
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT13073336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2783682OtherNCPDP PROVIDER IDENTIFICATION NUMBER