Provider Demographics
NPI:1790925840
Name:SAINT-MARK ENTERPRISES 1788 LLC
Entity Type:Organization
Organization Name:SAINT-MARK ENTERPRISES 1788 LLC
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-518-2427
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-0098
Mailing Address - Country:US
Mailing Address - Phone:509-276-5081
Mailing Address - Fax:509-276-7653
Practice Address - Street 1:11 E H ST
Practice Address - Street 2:SUITE A
Practice Address - City:DEER PARK
Practice Address - State:WA
Practice Address - Zip Code:99006-7178
Practice Address - Country:US
Practice Address - Phone:509-276-5081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-03
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6032213Medicaid
WA6220930001Medicare NSC
WAG8881423Medicare PIN