Provider Demographics
NPI:1043364490
Name:MOUNTAIN VALLEY RX 05 INC
Entity type:Organization
Organization Name:MOUNTAIN VALLEY RX 05 INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BEAU
Authorized Official - Middle Name:
Authorized Official - Last Name:KISABETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-388-3211
Mailing Address - Street 1:PO BOX 385
Mailing Address - Street 2:
Mailing Address - City:DANDRIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37725-0385
Mailing Address - Country:US
Mailing Address - Phone:865-475-9969
Mailing Address - Fax:865-475-9901
Practice Address - Street 1:153 E BROADWAY BLVD
Practice Address - Street 2:STE 103
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-2517
Practice Address - Country:US
Practice Address - Phone:865-471-5111
Practice Address - Fax:865-471-5199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TN39183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4437364OtherNCPDP PROVIDER IDENTIFICATION NUMBER
4314720002Medicare NSC