MEDICARE: SANTA TERESA PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2125859	OTHER		PK
2	0356786	OTHER		NCPDP

General Provider Information

NPI Number	:	1851604524
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANTA TERESA PHARMACY LLC

Provider Business Mailing Address
First Line	:	151 S OAK AVE STE 200
Second Line	:
City	:	SAN LUIS
State	:	AZ
Zip	:	85336-0756
Country	:	US
Telephone Number	:	928-328-1000
Fax Number	:	928-328-1001

Provider Business Practice Location Address
First Line	:	151 S OAK AVE STE 200
Second Line	:
City	:	SAN LUIS
State	:	AZ
Zip	:	85336-0756
Country	:	US
Telephone Number	:	928-328-1000
Fax Number	:	928-328-1001

Authorized Official
Title or Position	:	MEMBER
Name	:	RAJ SHAH
Credential	:
Telephone Number	:	928-328-1000

Provider Enumeration Date	:	07/22/2010
Last Update Date	:	11/16/2021

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Directions to “SANTA TERESA PHARMACY LLC ” Practice Location

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