Healthcare Provider Details

I. General information

NPI: 1447635578
Provider Name (Legal Business Name): SAINT MARY'S MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6255 SHARLANDS AVE
RENO NV
89523-2882
US

IV. Provider business mailing address

1801 W OLYMPIC BLVD
PASADENA CA
91199-0001
US

V. Phone/Fax

Practice location:
  • Phone: 775-770-6672
  • Fax: 775-770-6675
Mailing address:
  • Phone: 775-770-6672
  • Fax: 775-770-6675

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 NumberASC03452
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: HELEN LIDHOLM
Title or Position: CEO/AO
Credential:
Phone: 775-770-3230