Provider Demographics
NPI:1114689437
Name:ST MARY RX INC
Entity Type:Organization
Organization Name:ST MARY RX INC
Other - Org Name:ST GEORGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MINA
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-381-0500
Mailing Address - Street 1:11003 LAKEWOOD BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-3876
Mailing Address - Country:US
Mailing Address - Phone:562-381-0500
Mailing Address - Fax:562-381-0400
Practice Address - Street 1:11003 LAKEWOOD BLVD STE 101
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-3876
Practice Address - Country:US
Practice Address - Phone:562-381-0500
Practice Address - Fax:562-381-0400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-13
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy