Provider Demographics
NPI:1770834111
Name:SAINT-MARK ENTERPRISES 1196 LLC
Entity Type:Organization
Organization Name:SAINT-MARK ENTERPRISES 1196 LLC
Other - Org Name:THE MEDICINE SHOPPE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RIK
Authorized Official - Middle Name:
Authorized Official - Last Name:ST GERMAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-650-5514
Mailing Address - Street 1:1070 VIA SAINT LUCIA PL
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89011-0873
Mailing Address - Country:US
Mailing Address - Phone:206-650-5541
Mailing Address - Fax:702-568-8676
Practice Address - Street 1:1000 ADAMS ST
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-4208
Practice Address - Country:US
Practice Address - Phone:620-792-3030
Practice Address - Fax:620-792-4971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-25
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
KS2-104243336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2137647OtherPK