Provider Demographics
NPI:1760494033
Name:PHARMERICA MOUNTAIN LLC
Entity Type:Organization
Organization Name:PHARMERICA MOUNTAIN LLC
Other - Org Name:PHARMERICA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-630-7429
Mailing Address - Street 1:805 N WHITTINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-7101
Mailing Address - Country:US
Mailing Address - Phone:502-627-7000
Mailing Address - Fax:502-627-7401
Practice Address - Street 1:2950 E MAGIC VIEW DR STE 190
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-887-1951
Practice Address - Fax:208-895-9825
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHARMERICA CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1929LS3336L0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID47154LSOtherBOARD OF PHARMACY
AK1704147Medicaid
WA6022362Medicaid
ID807106500Medicaid
ORRP-0002900OtherBOARD OF PHARMACY
OR276268Medicaid
WA6022362Medicaid