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  5. MOUNTAIN PINE DERMATOLOGY PLLC

MOUNTAIN PINE DERMATOLOGY PLLC

Company Details

Name: MOUNTAIN PINE DERMATOLOGY PLLC
Jurisdiction: Idaho
Legal type: Limited Liability Company (D)
Status: Active-Existing
Date of registration: 08 Mar 2016 (9 years ago)
Financial Date End: 31 Mar 2026
Date dissolved: 12 Jun 2024
Entity Number: 494483
Place of Formation: IDAHO
File Number: 494483
ZIP code: 83646
County: Ada County
Mailing Address: STE 100 4664 N PENNGROVE WAY MERIDIAN, ID 83646-7442

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
MOUNTAIN PINE DERMATOLOGY 401(K) PLAN 2023 811701258 2024-10-04 MOUNTAIN PINE DERMATOLOGY 53
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2018-04-01
Business code 621111
Sponsor’s telephone number 2088987467
Plan sponsor’s address 4664 N PENNGROVE WAY, SUITE 100, MERIDIAN, ID, 83646

Signature of
Role Plan administrator
Date 2024-10-04
Name of individual signing RICHARD SCOTT THOMAS
Valid signature Filed with authorized/valid electronic signature
MOUNTAIN PINE DERMATOLOGY 401(K) PLAN 2023 811701258 2024-07-29 MOUNTAIN PINE DERMATOLOGY 50
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2018-04-01
Business code 621111
Sponsor’s telephone number 2088987467
Plan sponsor’s address 4664 N PENNGROVE WAY, SUITE 100, MERIDIAN, ID, 83646

Signature of
Role Plan administrator
Date 2024-07-29
Name of individual signing RICHARD SCOTT THOMAS
Valid signature Filed with authorized/valid electronic signature
MOUNTAIN PINE DERMATOLOGY 401(K) PLAN 2022 811701258 2023-08-10 MOUNTAIN PINE DERMATOLOGY 37
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2018-04-01
Business code 621111
Sponsor’s telephone number 2088987467
Plan sponsor’s address 4664 N PENNGROVE WAY, SUITE 100, MERIDIAN, ID, 83646

Signature of
Role Plan administrator
Date 2023-08-10
Name of individual signing RICHARD SCOTT THOMAS
Valid signature Filed with authorized/valid electronic signature
MOUNTAIN PINE DERMATOLOGY 401(K) PLAN 2021 811701258 2022-07-20 MOUNTAIN PINE DERMATOLOGY 27
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2018-04-01
Business code 621111
Sponsor’s telephone number 2088987467
Plan sponsor’s address 4664 N PENNGROVE WAY, SUITE 100, MERIDIAN, ID, 83646

Signature of
Role Plan administrator
Date 2022-07-20
Name of individual signing RICHARD SCOTT THOMAS
Valid signature Filed with authorized/valid electronic signature
MOUNTAIN PINE DERMATOLOGY 401(K) PLAN 2020 811701258 2021-07-28 MOUNTAIN PINE DERMATOLOGY 16
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2018-04-01
Business code 621111
Sponsor’s telephone number 2088987467
Plan sponsor’s address 1576 W. DEER CREST ST STE 100, MERIDIAN, ID, 83646

Signature of
Role Plan administrator
Date 2021-07-28
Name of individual signing RICHARD SCOTT THOMAS
Valid signature Filed with authorized/valid electronic signature
MOUNTAIN PINE DERMATOLOGY 401K PLAN 2019 811701258 2020-10-15 MOUNTAIN PINE DERMATOLOGY, PLLC 12
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2018-04-01
Business code 621111
Sponsor’s telephone number 2088987467
Plan sponsor’s address 1576 W. DEER CREST ST., SUITE 100, MERIDIAN, ID, 83646

Signature of
Role Plan administrator
Date 2020-10-15
Name of individual signing STEFANIE THOMAS
Valid signature Filed with authorized/valid electronic signature
MOUNTAIN PINE DERMATOLOGY 401K 2018 811701258 2019-05-06 MOUNTAIN PINE DERMATOLOGY 10
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2018-04-01
Business code 621111
Sponsor’s telephone number 2088987467
Plan sponsor’s address 1576 W. DEER CREST ST STE 100, MERIDIAN, ID, 83646

Signature of
Role Plan administrator
Date 2019-05-06
Name of individual signing DR. RICHARD SCOTT THOMAS
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
RICHARD SCOTT THOMAS Agent 4664 N PENNGROVE WAY, STE 100, MERIDIAN, ID 83646

Manager

Name Role Address Appointed On
Stefanie Thomas Manager 4664 N PENNGROVE WAY, MERIDIAN, ID 83646-7442 2020-08-11

Filing

Filing Name Filing Number Filing date
Annual Report 0006198305 2025-04-07
Application for Reinstatement 0005933682 2024-10-08
Dissolution/Revocation - Administrative 0005774983 2024-06-12
Annual Report 0005154344 2023-03-13
Change of Registered Office/Agent/Both (by Entity) 0004591942 2022-02-03
Annual Report 0004592045 2022-02-03
Annual Report 0004235505 2021-04-06
Annual Report 0003968521 2020-08-11
Statement of Change of Business Mailing Address 0003935768 2020-07-09
Amendment to Certificate 0003463029 2019-03-26

Paycheck Protection Program

Loan Number Loan Funded Date SBA Origination Office Code Loan Delivery Method Borrower Street Address
3001047110 2020-04-11 1087 PPP 1576 W Deer Crest St. #100, MERIDIAN, ID, 83646-4643
Loan Status Date 2021-03-19
Loan Status Paid in Full
Loan Maturity in Months 24
SBA Guaranty Percentage 100
Loan Approval Amount (at origination) 215000
Loan Approval Amount (current) 215000
Undisbursed Amount 0
Franchise Name -
Lender Location ID 20132
Servicing Lender Name D. L. Evans Bank
Servicing Lender Address 375 N Overland Ave, BURLEY, ID, 83318-3432
Rural or Urban Indicator U
Hubzone N
LMI N
Business Age Description Existing or more than 2 years old
Project Address MERIDIAN, ADA, ID, 83646-4643
Project Congressional District ID-01
Number of Employees 75
NAICS code 621111
Borrower Race Unanswered
Borrower Ethnicity Not Hispanic or Latino
Business Type Limited Liability Company(LLC)
Originating Lender ID 20132
Originating Lender Name D. L. Evans Bank
Originating Lender Address BURLEY, ID
Gender Male Owned
Veteran Non-Veteran
Forgiveness Amount 216837.81
Forgiveness Paid Date 2021-02-24

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Date of last update: 09 Apr 2025

Sources: Idaho Secretary of State

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