Healthcare Provider Details

I. General information

NPI: 1740423573
Provider Name (Legal Business Name): ST MARY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 02/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1290 W BAY DR
LARGO FL
33770-2204
US

IV. Provider business mailing address

1290 W BAY DR
LARGO FL
33770-2204
US

V. Phone/Fax

Practice location:
  • Phone: 727-585-1333
  • Fax: 727-585-1344
Mailing address:
  • Phone: 727-585-1333
  • Fax: 727-585-1344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH23976
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JOHN SHAKER
Title or Position: PHARMACIST (PARTNER)
Credential:
Phone: 727-637-8174