Provider Demographics
NPI:1417235953
Name:ST MARY PHARMACY LLC
Entity Type:Organization
Organization Name:ST MARY PHARMACY LLC
Other - Org Name:ST MARY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-384-1234
Mailing Address - Street 1:PO BOX 3230
Mailing Address - Street 2:
Mailing Address - City:MORGAN CITY
Mailing Address - State:LA
Mailing Address - Zip Code:70381-3230
Mailing Address - Country:US
Mailing Address - Phone:985-384-1234
Mailing Address - Fax:985-384-1233
Practice Address - Street 1:1124 7TH ST
Practice Address - Street 2:
Practice Address - City:MORGAN CITY
Practice Address - State:LA
Practice Address - Zip Code:70380-1951
Practice Address - Country:US
Practice Address - Phone:985-384-1234
Practice Address - Fax:985-384-1233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-02
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X
LA6396-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2200887Medicaid
2131119OtherPK