Provider Demographics
NPI:1225254576
Name:ST MARYS MANAGED PRESCRIPTION PROGRAM
Entity Type:Organization
Organization Name:ST MARYS MANAGED PRESCRIPTION PROGRAM
Other - Org Name:MANAGED PRESCRIPTION PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:WICKIS
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:520-297-3800
Mailing Address - Street 1:10860 N MAVINEE DR
Mailing Address - Street 2:
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85737-9526
Mailing Address - Country:US
Mailing Address - Phone:520-297-3800
Mailing Address - Fax:520-297-3466
Practice Address - Street 1:10860 N MAVINEE DR
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85737-9526
Practice Address - Country:US
Practice Address - Phone:520-297-3800
Practice Address - Fax:520-297-3466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6870183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty