Healthcare Provider Details

I. General information

NPI: 1770988362
Provider Name (Legal Business Name): ST JAMES LONG TERM CARE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2014
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20616 N CAVE CREEK RD STE 111
PHOENIX AZ
85024-4451
US

IV. Provider business mailing address

20616 N CAVE CREEK RD STE 111
PHOENIX AZ
85024-4451
US

V. Phone/Fax

Practice location:
  • Phone: 480-662-3865
  • Fax: 480-494-8558
Mailing address:
  • Phone: 480-662-3865
  • Fax: 602-354-4336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS013212
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberT042375
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberY006254
License Number StateAZ

VIII. Authorized Official

Name: DR. BRIAN LIM MARASIGAN
Title or Position: MANAGER, CHIEF OPERATING OFFICER
Credential: MD
Phone: 480-662-3865