Basic Information
| Provider Information | |||||||||
| NPI: | 1104919216 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. MARIE CLINIC, P.A. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ST. MARIE CLINIC, P.A. PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 305 E EXPRESSWAY 83 | ||||||||
| Address2: | |||||||||
| City: | MISSION | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785725560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9565857401 | ||||||||
| FaxNumber: | 9565801788 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 E EXPRESSWAY 83 | ||||||||
| Address2: | |||||||||
| City: | MISSION | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785725560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9565852009 | ||||||||
| FaxNumber: | 9565835833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 08/14/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARRILLO | ||||||||
| AuthorizedOfficialFirstName: | EDUARDO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9565857401 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | 45-37380 | TX | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 145560 | 01 | TX | VENDOR DRUG NUMBER | OTHER | 45-37380 | 01 | TX | NCPDP NUMBER | OTHER |