Healthcare Provider Details

I. General information

NPI: 1417197567
Provider Name (Legal Business Name): SAINT-MARK ENTERPRISES 106 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 PROFESSIONAL WAY
SHELTON WA
98584-4404
US

IV. Provider business mailing address

PO BOX 98
EUREKA MO
63025-0098
US

V. Phone/Fax

Practice location:
  • Phone: 360-426-4272
  • Fax: 360-426-6977
Mailing address:
  • Phone: 314-518-2427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MARK A MILLER
Title or Position: OWNER
Credential:
Phone: 314-518-2427