Provider Demographics
NPI:1558451476
Name:MOUNTAIN CLINIC PHARMACY LLC
Entity Type:Organization
Organization Name:MOUNTAIN CLINIC PHARMACY LLC
Other - Org Name:MOUNTAIN CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:BROOKS
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:606-438-2445
Mailing Address - Street 1:233 E MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-1954
Mailing Address - Country:US
Mailing Address - Phone:606-436-0045
Mailing Address - Fax:606-436-0048
Practice Address - Street 1:233 E MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-1954
Practice Address - Country:US
Practice Address - Phone:606-436-0045
Practice Address - Fax:606-436-0048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP071433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54012190Medicaid
1829742OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1829742OtherNCPDP PROVIDER IDENTIFICATION NUMBER