Provider Demographics
NPI:1376564310
Name:MARIOS PHARMACY INC
Entity Type:Organization
Organization Name:MARIOS PHARMACY INC
Other - Org Name:STONEGATE PHARMACY ON BROADWAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:210-913-2244
Mailing Address - Street 1:2501 W WILLIAM CANNON DR
Mailing Address - Street 2:STE. 203
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-5281
Mailing Address - Country:US
Mailing Address - Phone:512-707-2300
Mailing Address - Fax:
Practice Address - Street 1:2515 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-1037
Practice Address - Country:US
Practice Address - Phone:210-354-0101
Practice Address - Fax:210-354-0404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TX241123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145542Medicaid
2097195OtherPK