Provider Demographics
NPI:1568473072
Name:MOUNTAIN APOTHECARY
Entity Type:Organization
Organization Name:MOUNTAIN APOTHECARY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:WESTMORELAND
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:606-789-6150
Mailing Address - Street 1:834 S MAYO TRL
Mailing Address - Street 2:
Mailing Address - City:PAINTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41240-1384
Mailing Address - Country:US
Mailing Address - Phone:606-789-6150
Mailing Address - Fax:606-789-6156
Practice Address - Street 1:834 S MAYO TRL
Practice Address - Street 2:
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240-1384
Practice Address - Country:US
Practice Address - Phone:606-789-6150
Practice Address - Fax:606-789-6156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP025443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2031854OtherPK
KY54029152Medicaid
0647660001Medicare NSC