MEDICARE: SAINT-MARK ENTERPRISES #1153 LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	2-10431	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2138312	OTHER		PK

General Provider Information

NPI Number	:	1346584935
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAINT-MARK ENTERPRISES #1153 LLC

Provider Business Mailing Address
First Line	:	1070 VIA SAINT LUCIA PL
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89011-0873
Country	:	US
Telephone Number	:	206-650-5541
Fax Number	:	702-568-8676

Provider Business Practice Location Address
First Line	:	1001 W 11TH ST
Second Line	:
City	:	COFFEYVILLE
State	:	KS
Zip	:	67337-4220
Country	:	US
Telephone Number	:	620-251-2150
Fax Number	:	620-251-0022

Authorized Official
Title or Position	:	OWNER
Name	:	RIK ST GERMAIN
Credential	:
Telephone Number	:	206-650-5514

Provider Enumeration Date	:	11/20/2012
Last Update Date	:	07/05/2016

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