Provider Demographics
NPI:1346584935
Name:SAINT-MARK ENTERPRISES #1153 LLC
Entity Type:Organization
Organization Name:SAINT-MARK ENTERPRISES #1153 LLC
Other - Org Name:THE MEDICINE SHOPPE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RIK
Authorized Official - Middle Name:
Authorized Official - Last Name:ST GERMAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-650-5514
Mailing Address - Street 1:1070 VIA SAINT LUCIA PL
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89011-0873
Mailing Address - Country:US
Mailing Address - Phone:206-650-5541
Mailing Address - Fax:702-568-8676
Practice Address - Street 1:1001 W 11TH ST
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-4220
Practice Address - Country:US
Practice Address - Phone:620-251-2150
Practice Address - Fax:620-251-0022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-20
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2-104313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2138312OtherPK
1720641OtherNCPDP PROVIDER IDENTIFICATION NUMBER