Provider Demographics
NPI:1861829228
Name:ST. MARY'S MEDICAL CENTER INC
Entity Type:Organization
Organization Name:ST. MARY'S MEDICAL CENTER INC
Other - Org Name:THE PHARMACY @ HIMG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY AMBULATORY SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SAUNDERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:304-526-1234
Mailing Address - Street 1:5170 US ROUTE 60
Mailing Address - Street 2:STE 150
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-2004
Mailing Address - Country:US
Mailing Address - Phone:304-399-3784
Mailing Address - Fax:
Practice Address - Street 1:5170 US ROUTE 60
Practice Address - Street 2:STE 150
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2004
Practice Address - Country:US
Practice Address - Phone:304-399-3784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-01
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP0552459333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWX0000033513Medicaid