Provider Demographics
NPI:1891852232
Name:BLACK MOUNTIN NUERO MEDICAL TREATMENT CENTER
Entity Type:Organization
Organization Name:BLACK MOUNTIN NUERO MEDICAL TREATMENT CENTER
Other - Org Name:BLACK MOUNTAIN CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NORM
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:828-259-6745
Mailing Address - Street 1:CBO DHHS CONTROLLERS OFC
Mailing Address - Street 2:2021 MAIL SERVICE CENTER
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27699-0001
Mailing Address - Country:US
Mailing Address - Phone:919-733-9867
Mailing Address - Fax:919-733-1512
Practice Address - Street 1:932 OLD US HWY 70 W
Practice Address - Street 2:
Practice Address - City:BLACK MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28711-2547
Practice Address - Country:US
Practice Address - Phone:828-259-6745
Practice Address - Fax:828-259-6680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC022673336L0003X, 3336L0003X
NC1861610222314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2065189OtherPK
NC1861610222OtherSTATE MEDICAL PROVIDER #
3403906OtherOTHER ID NUMBER-COMMERCIAL NUMBER