Provider Demographics
NPI:1578503488
Name:MOUNTAINAIR MEDS & MORE, LLC
Entity Type:Organization
Organization Name:MOUNTAINAIR MEDS & MORE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:ALEXANDRA
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:505-847-0242
Mailing Address - Street 1:PO BOX 969
Mailing Address - Street 2:
Mailing Address - City:MOUNTAINAIR
Mailing Address - State:NM
Mailing Address - Zip Code:87036-0969
Mailing Address - Country:US
Mailing Address - Phone:505-847-0242
Mailing Address - Fax:505-847-0252
Practice Address - Street 1:111 W. BROADWAY
Practice Address - Street 2:
Practice Address - City:MOUNTAINAIR
Practice Address - State:NM
Practice Address - Zip Code:87036
Practice Address - Country:US
Practice Address - Phone:505-847-0242
Practice Address - Fax:505-847-0252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00006163183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM66832Medicaid
NM3207467OtherNABP NUMBER
NM66832Medicaid