Provider Demographics
NPI:1588937395
Name:MOUNTAIN CARE PHARMACY IDAHO
Entity type:Organization
Organization Name:MOUNTAIN CARE PHARMACY IDAHO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:STONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-747-7191
Mailing Address - Street 1:1030 BELLWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-4494
Mailing Address - Country:US
Mailing Address - Phone:801-747-7191
Mailing Address - Fax:801-747-7192
Practice Address - Street 1:1753 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3045
Practice Address - Country:US
Practice Address - Phone:208-932-1260
Practice Address - Fax:208-523-2330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
ID18014LS3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1308661OtherNCPDP PROVIDER IDENTIFICATION NUMBER