1306094206 NPI number — ST MARYS PHARMACY INC

Table of content: (NPI 1306094206)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306094206 NPI number — ST MARYS PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST MARYS PHARMACY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SMP PHARMACY AND HOME MEDICAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306094206
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 RAILROAD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT MARYS
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15857-1729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-834-3017
Provider Business Mailing Address Fax Number:
814-834-6510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
190 N FRALEY ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
KANE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16735-1165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-837-8500
Provider Business Practice Location Address Fax Number:
814-837-8501
Provider Enumeration Date:
09/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BENNETT
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
DIRECTOR RETAIL PHARMACY OPERATIONS
Authorized Official Telephone Number:
814-299-7553

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PP481849 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2116840 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1007711390007 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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