Healthcare Provider Details

I. General information

NPI: 1619919040
Provider Name (Legal Business Name): PAYLESS MARKETS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 03/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 S ROUTE 4 STE 118, AGANA SHOPPING CTR
CHALAN PAGO GU
96910
US

IV. Provider business mailing address

302 S ROUTE 4 STE 118, AGANA SHOPPING CTR
CHALAN PAGO GU
96910
US

V. Phone/Fax

Practice location:
  • Phone: 671-477-3627
  • Fax: 671-477-5589
Mailing address:
  • Phone: 671-477-3627
  • Fax: 671-477-5589

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 NumberPCY037
License Number StateGU

VIII. Authorized Official

Name: MIKE BENITO
Title or Position: GENERAL MANAGER PAYLESS MRKTS
Credential: RPH
Phone: 671-477-3627