Basic Information
| Provider Information | |||||||||
| NPI: | 1346261575 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHARMERICA MOUNTAIN LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PHARMERICA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3802 CORPOREX PARK DR | ||||||||
| Address2: | STE 150 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336191125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133186039 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3825 W CHEYENNE AVE # 603 | ||||||||
| Address2: | |||||||||
| City: | NORTH LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890323408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028711920 | ||||||||
| FaxNumber: | 7028714203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | REED | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5023942100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHARMERICA CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | PH01635 | NV | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | PHC01635 | 01 | NV | BOARD OF PHARMACY | OTHER | 003702002 | 05 | NV | MEDICAID | 10562714-1708 | 01 | UT | BOARD OF PHARMACY | OTHER | 10562714-8913 | 01 | UT | CONTROLLED SUBSTANCE | OTHER | 11465757-1708 | 01 | UT | BOARD OF PHARMACY | OTHER | 11465757-8913 | 01 | UT | BOARD OF PHARMACY | OTHER | 3000009 | 05 | UT | MEDICAID |