Provider Demographics
NPI:1366748238
Name:MOUNT OLYMPUS COMPOUNDING LLC
Entity type:Organization
Organization Name:MOUNT OLYMPUS COMPOUNDING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER, LLC
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KILPATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-824-6968
Mailing Address - Street 1:PO BOX 1344
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-1344
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:392 E 12300 S
Practice Address - Street 2:SUITE A
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8181
Practice Address - Country:US
Practice Address - Phone:801-278-9008
Practice Address - Fax:801-849-0399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-09
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT876450417033336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4611960OtherNCPDP