Provider Demographics
NPI:1306854385
Name:ST MARYS PHARMACIES INC
Entity Type:Organization
Organization Name:ST MARYS PHARMACIES INC
Other - Org Name:MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:AWAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-997-4702
Mailing Address - Street 1:610 GATEWAY CENTER WAY
Mailing Address - Street 2:STE A
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4533
Mailing Address - Country:US
Mailing Address - Phone:619-238-9501
Mailing Address - Fax:619-398-2929
Practice Address - Street 1:610 GATEWAY CENTER WAY
Practice Address - Street 2:STE A
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-4533
Practice Address - Country:US
Practice Address - Phone:619-238-9501
Practice Address - Fax:619-398-2929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
CA463303336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA456440Medicaid
1997430OtherPK
0225250001Medicare NSC