Provider Demographics
NPI:1881272854
Name:MOUNTAIN STATES HEALTH ALLIANCE
Entity type:Organization
Organization Name:MOUNTAIN STATES HEALTH ALLIANCE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:HILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-302-3467
Mailing Address - Street 1:2 PROFESSIONAL PARK DR STE 15
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6584
Mailing Address - Country:US
Mailing Address - Phone:423-434-7443
Mailing Address - Fax:423-302-3537
Practice Address - Street 1:1 PROFESSIONAL PARK DR STE 21
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6909
Practice Address - Country:US
Practice Address - Phone:423-431-7760
Practice Address - Fax:423-610-3361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-31
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0440063Medicaid