Provider Demographics
NPI:1346774619
Name:ST. JAMES MTM PHARMACY, LLC
Entity Type:Organization
Organization Name:ST. JAMES MTM PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, LLC MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARASIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-662-3865
Mailing Address - Street 1:20624 N CAVE CREEK RD STE 142
Mailing Address - Street 2:STE 142
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024-4453
Mailing Address - Country:US
Mailing Address - Phone:480-662-3865
Mailing Address - Fax:
Practice Address - Street 1:3954 E WALLER LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4916
Practice Address - Country:US
Practice Address - Phone:480-662-3865
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS014670183500000X
AZMD47798208D00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty