1083736383 NPI number — ST GEORGE PHARMACY LLC

Table of content: ELENI MAVRAKIS DMD (NPI 1710370218)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083736383 NPI number — ST GEORGE PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST GEORGE PHARMACY LLC
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:
Provider Other Organization Name Type Code:
6
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:
1083736383
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
557 ENGLISHTOWN RD
Provider Second Line Business Mailing Address:
STE 14
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08831-3042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-446-5445
Provider Business Mailing Address Fax Number:
732-446-0811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
557 ENGLISHTOWN RD
Provider Second Line Business Practice Location Address:
STE 14
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08831-3042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-446-5445
Provider Business Practice Location Address Fax Number:
732-446-0811
Provider Enumeration Date:
04/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNAN
Authorized Official First Name:
TERIZA
Authorized Official Middle Name:
Authorized Official Title or Position:
PIC
Authorized Official Telephone Number:
732-446-5445

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  28RS00668100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3194228 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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