Healthcare Provider Details

I. General information

NPI: 1578503488
Provider Name (Legal Business Name): MOUNTAINAIR MEDS & MORE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W. BROADWAY
MOUNTAINAIR NM
87036
US

IV. Provider business mailing address

PO BOX 969
MOUNTAINAIR NM
87036-0969
US

V. Phone/Fax

Practice location:
  • Phone: 505-847-0242
  • Fax: 505-847-0252
Mailing address:
  • Phone: 505-847-0242
  • Fax: 505-847-0252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00006163
License Number StateNM

VIII. Authorized Official

Name: MS. KATHLEEN ALEXANDRA WEST
Title or Position: CO-OWNER
Credential: RPH
Phone: 505-847-0242