Provider Demographics
NPI:1336228006
Name:MOUNTAIN LAKE PHARMACY INC
Entity Type:Organization
Organization Name:MOUNTAIN LAKE PHARMACY INC
Other - Org Name:MOUNTAIN LAKE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT PIC
Authorized Official - Prefix:
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-872-9000
Mailing Address - Street 1:1129 BROAD ST
Mailing Address - Street 2:STE 100
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-1838
Mailing Address - Country:US
Mailing Address - Phone:304-872-9000
Mailing Address - Fax:304-872-4419
Practice Address - Street 1:1129 BROAD ST
Practice Address - Street 2:STE 100
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-1838
Practice Address - Country:US
Practice Address - Phone:304-872-9000
Practice Address - Fax:304-872-4419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVSP05523143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6001398000Medicaid
5054046OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5452150001Medicare NSC