Healthcare Provider Details

I. General information

NPI: 1477760379
Provider Name (Legal Business Name): ST. MARY MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 12/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54391 VILLAGE CENTER DR # 6
IDYLLWILD CA
92549-9997
US

IV. Provider business mailing address

54391 VILLAGE CENTER DR # 6
IDYLLWILD CA
92549-9997
US

V. Phone/Fax

Practice location:
  • Phone: 951-659-2135
  • Fax:
Mailing address:
  • Phone: 951-659-2135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY48585
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number56117
License Number StateCA

VIII. Authorized Official

Name: MR. JAMES MARIO LA PONZA
Title or Position: VICE PRESIDENT/PHARMACIST-IN-CHARGE
Credential: PHARM.D
Phone: 951-659-2135