Provider Demographics
NPI:1972665396
Name:MOUNTAIN WEST MEDICINE, INC.
Entity type:Organization
Organization Name:MOUNTAIN WEST MEDICINE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:LINDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:801-295-6979
Mailing Address - Street 1:1551 S RENAISSANCE TOWNE DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010
Mailing Address - Country:US
Mailing Address - Phone:801-295-6979
Mailing Address - Fax:801-295-6989
Practice Address - Street 1:1551 S RENAISSANCE TOWNE DR
Practice Address - Street 2:SUITE 104
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010
Practice Address - Country:US
Practice Address - Phone:801-295-6979
Practice Address - Fax:801-295-6989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5731786-17033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT201309057001Medicaid