Provider Demographics
NPI:1902043227
Name:SAINT-MARK ENTERPRISES 1890 LLC
Entity Type:Organization
Organization Name:SAINT-MARK ENTERPRISES 1890 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:314-518-2427
Mailing Address - Fax:
Practice Address - Street 1:2425 DAVE WARD DR
Practice Address - Street 2:SUITE 602
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-8686
Practice Address - Country:US
Practice Address - Phone:501-329-7777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAINT-MARK ENTERPRISES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-08
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0423044OtherNCPDP #
AR175898407Medicaid
AR175898407Medicaid
AR5G934Medicare PIN