=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770394397
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST GEORGE PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2025
-----------------------------------------------------
Last Update Date | 01/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 99 STUYVESANT PL
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10301-1917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-447-0333
-----------------------------------------------------
Fax | 718-447-0398
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 99 STUYVESANT PL
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10301-1917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-447-0333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | OMAR MOHAMED
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-667-4300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------