Provider Demographics
NPI:1881301323
Name:BLUE MOUNTAIN PHARMACY INC
Entity type:Organization
Organization Name:BLUE MOUNTAIN PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:DYCE
Authorized Official - Last Name:THURSTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:509-382-2536
Mailing Address - Street 1:176 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:WA
Mailing Address - Zip Code:99328-1393
Mailing Address - Country:US
Mailing Address - Phone:509-382-2536
Mailing Address - Fax:509-382-2067
Practice Address - Street 1:764 MAIN ST
Practice Address - Street 2:
Practice Address - City:POMEROY
Practice Address - State:WA
Practice Address - Zip Code:99347-9718
Practice Address - Country:US
Practice Address - Phone:509-843-1821
Practice Address - Fax:509-843-3447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-03
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2243871Medicaid