MEDICARE: MOUNTAIN SPECIALTY PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1073326161
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAIN SPECIALTY PHARMACY LLC

Provider Business Mailing Address
First Line	:	1183 S HAIRSTON RD STE C
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30088-2796
Country	:	US
Telephone Number	:	770-299-2965
Fax Number	:	770-299-2966

Provider Business Practice Location Address
First Line	:	1183 S HAIRSTON RD STE C
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30088-2796
Country	:	US
Telephone Number	:	770-299-2965
Fax Number	:	770-299-2966

Authorized Official
Title or Position	:	OWNER
Name	:	PRITIBEN PATEL
Credential	:
Telephone Number	:	770-299-2965

Provider Enumeration Date	:	01/31/2025
Last Update Date	:	01/31/2025

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