=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770834111
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAINT-MARK ENTERPRISES 1196 LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2012
-----------------------------------------------------
Last Update Date | 11/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 ADAMS ST
-----------------------------------------------------
City | GREAT BEND
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67530-4208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-792-3030
-----------------------------------------------------
Fax | 620-792-4971
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1070 VIA SAINT LUCIA PL
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89011-0873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-650-5541
-----------------------------------------------------
Fax | 702-568-8676
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RIK ST GERMAIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 206-650-5514
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 2-10424
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------