Provider Demographics
NPI:1689804551
Name:ST. MARIE CLINIC, P.A. PHARMACY
Entity Type:Organization
Organization Name:ST. MARIE CLINIC, P.A. PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-585-7401
Mailing Address - Street 1:305 E EXPRESSWAY 83
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-5560
Mailing Address - Country:US
Mailing Address - Phone:956-585-7401
Mailing Address - Fax:956-583-5833
Practice Address - Street 1:1905 E. MONTE CRISTO ROAD STE. C
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78541-0333
Practice Address - Country:US
Practice Address - Phone:956-287-1831
Practice Address - Fax:956-287-7832
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARIE CLINIC, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-24
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX26174OtherSTATE LICENSE NUMBER