Provider Demographics
NPI:1669619094
Name:SAINT-MARK ENTERPRISES 1906 LLC
Entity type:Organization
Organization Name:SAINT-MARK ENTERPRISES 1906 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:2125 COLLEGE AVE STE 1
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-6387
Practice Address - Country:US
Practice Address - Phone:501-327-8088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0423070OtherNCPDP #
AR175902407Medicaid
AR10653Medicare PIN
AR6219650001Medicare NSC