Healthcare Provider Details

I. General information

NPI: 1881272854
Provider Name (Legal Business Name): MOUNTAIN STATES HEALTH ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 04/17/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PROFESSIONAL PARK DR STE 21
JOHNSON CITY TN
37604-6909
US

IV. Provider business mailing address

2 PROFESSIONAL PARK DR STE 15
JOHNSON CITY TN
37604-6584
US

V. Phone/Fax

Practice location:
  • Phone: 423-431-7760
  • Fax: 423-610-3361
Mailing address:
  • Phone: 423-434-7443
  • Fax: 423-302-3537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SHANE EDWIN HILTON
Title or Position: EVP/CFO
Credential:
Phone: 423-302-3467