Provider Demographics
NPI:1477713667
Name:ST MARKS PHARMACY LLC
Entity Type:Organization
Organization Name:ST MARKS PHARMACY LLC
Other - Org Name:ST MARKS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WAGIH
Authorized Official - Middle Name:
Authorized Official - Last Name:MANKARIOUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-751-7630
Mailing Address - Street 1:4954 RIDGEMOOR BLVD
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-1744
Mailing Address - Country:US
Mailing Address - Phone:727-772-7070
Mailing Address - Fax:727-772-7010
Practice Address - Street 1:4954 RIDGEMOOR BLVD
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34685-1744
Practice Address - Country:US
Practice Address - Phone:727-772-7070
Practice Address - Fax:727-772-7010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH234023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2005602OtherPK