| Organization Name: | MOUNTAIN LAKE PHARMACY INC |
| NPI Number: | 1336228006 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | HOWARD BOONE (PRESIDENT PIC) |
| Mailing Address: | 1129 Broad St Ste 100 Summersville |
| State: | WV US |
| Postal Code: | 266511838 |
| Phone Number: | 3048729000 |
| Fax Number: | 3048724419 |
| NPI Enumeration Date: | 11/03/2006 |
| NPI Last Update Date: | 09/10/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 333600000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Pharmacy |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A facility used by pharmacists for the compounding and dispensing of medicinal preparations and other associated professional and administrative services. A pharmacy is a facility whose primary function is to store, prepare and legally dispense prescription drugs under the professional supervision of a licensed pharmacist. It meets any licensing or certification standards set forth by the jurisdiction where it is located. |