Provider Demographics
NPI:1295225126
Name:ST CYRIL INC
Entity Type:Organization
Organization Name:ST CYRIL INC
Other - Org Name:MESA VERDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GENEVIEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENJAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-576-5875
Mailing Address - Street 1:1525 MESA VERDE DR E STE 101
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5221
Mailing Address - Country:US
Mailing Address - Phone:714-884-3574
Mailing Address - Fax:714-486-1027
Practice Address - Street 1:1525 MESA VERDE DR E STE 101
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5221
Practice Address - Country:US
Practice Address - Phone:714-884-3574
Practice Address - Fax:714-486-1027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-16
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY560363336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2177690OtherPK