Healthcare Provider Details

I. General information

NPI: 1770834111
Provider Name (Legal Business Name): SAINT-MARK ENTERPRISES 1196 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2012
Last Update Date: 11/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 ADAMS ST
GREAT BEND KS
67530-4208
US

IV. Provider business mailing address

1070 VIA SAINT LUCIA PL
HENDERSON NV
89011-0873
US

V. Phone/Fax

Practice location:
  • Phone: 620-792-3030
  • Fax: 620-792-4971
Mailing address:
  • Phone: 206-650-5541
  • Fax: 702-568-8676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2-10424
License Number StateKS

VIII. Authorized Official

Name: RIK ST GERMAIN
Title or Position: OWNER
Credential:
Phone: 206-650-5514