Basic Information
| Provider Information | |||||||||
| NPI: | 1689804551 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. MARIE CLINIC, P.A. PHARMACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 E EXPRESSWAY 83 | ||||||||
| Address2: | |||||||||
| City: | MISSION | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785725560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9565857401 | ||||||||
| FaxNumber: | 9565835833 | ||||||||
| Practice Location | |||||||||
| Address1: | 1905 E. MONTE CRISTO ROAD STE. C | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785410333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9562871831 | ||||||||
| FaxNumber: | 9562877832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2009 | ||||||||
| LastUpdateDate: | 07/24/2009 | ||||||||
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| AuthorizedOfficialLastName: | CARRILLO | ||||||||
| AuthorizedOfficialFirstName: | EDUARDO | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9565857401 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. MARIE CLINIC, P.A. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 26174 | TX | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 26174 | 01 | TX | STATE LICENSE NUMBER | OTHER |