Provider Demographics
NPI:1740423573
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 (PARTNER)
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-637-8174
Mailing Address - Street 1:1290 W BAY DR
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-2204
Mailing Address - Country:US
Mailing Address - Phone:727-585-1333
Mailing Address - Fax:727-585-1344
Practice Address - Street 1:1290 W BAY DR
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-2204
Practice Address - Country:US
Practice Address - Phone:727-585-1333
Practice Address - Fax:727-585-1344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-09
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X
FLPH239763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2119775OtherPK
FL001226300Medicaid