Provider Demographics
NPI:1578805172
Name:MOUNTAIN CARE PHARMACY TEXAS LLC
Entity Type:Organization
Organization Name:MOUNTAIN CARE PHARMACY TEXAS LLC
Other - Org Name:MOUNTAIN CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLRED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-747-7191
Mailing Address - Street 1:1030 W BELLWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-4494
Mailing Address - Country:US
Mailing Address - Phone:801-747-7191
Mailing Address - Fax:801-747-7192
Practice Address - Street 1:2010 CENTURY CENTER BLVD STE J
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-4963
Practice Address - Country:US
Practice Address - Phone:972-536-1986
Practice Address - Fax:972-579-8048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-21
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336H0001X
TX284333336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139306OtherPK