Provider Demographics
NPI:1356839559
Name:ST MARY PHARMACY INC
Entity Type:Organization
Organization Name:ST MARY PHARMACY INC
Other - Org Name:ST MARY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PIC
Authorized Official - Prefix:DR
Authorized Official - First Name:BESHOY
Authorized Official - Middle Name:I
Authorized Official - Last Name:GERGES
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:818-975-8004
Mailing Address - Street 1:8254 WHITE OAK AVE UNIT 4
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-4367
Mailing Address - Country:US
Mailing Address - Phone:818-975-8004
Mailing Address - Fax:818-975-8094
Practice Address - Street 1:8254 WHITE OAK AVE UNIT 4
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-4367
Practice Address - Country:US
Practice Address - Phone:818-975-8004
Practice Address - Fax:818-975-8094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-24
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA560963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY56096OtherBOARD OF PHARMACY PERMIT