Provider Demographics
NPI:1710002860
Name:ST. MARY HEALTH VENTURES, INC.
Entity Type:Organization
Organization Name:ST. MARY HEALTH VENTURES, INC.
Other - Org Name:MEDICAL MALL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:WAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-491-9929
Mailing Address - Street 1:1043 ELM AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3271
Mailing Address - Country:US
Mailing Address - Phone:562-491-9003
Mailing Address - Fax:562-495-9651
Practice Address - Street 1:1043 ELM AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3271
Practice Address - Country:US
Practice Address - Phone:562-491-9001
Practice Address - Fax:562-495-9651
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY HEALTH VENTURES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-20
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA506123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA41010AMedicaid
0582014OtherNCPDP
CA=========OtherIRS
CAPHA41010AMedicaid