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NPI Code Detail

MEDICARE: SAINT MARY'S MEDICAL GROUP INC

MEDICARE: SAINT MARY'S MEDICAL GROUP INC
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
13336C0004XCompounding Pharmacy
2333600000XPharmacy
33336C0003XCommunity/Retail PharmacyASC03452NV

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12155059OTHERPK

General Provider Information

NPI Number : 1447635578
Entity Type Code : Organization
Provider Name (Legal Business Name) : SAINT MARY'S MEDICAL GROUP INC
Provider Business Mailing Address
First Line : 1801 W OLYMPIC BLVD
Second Line :
City : PASADENA
State : CA
Zip : 91199-0001
Country : US
Telephone Number : 775-770-6672
Fax Number : 775-770-6675
Provider Business Practice Location Address
First Line : 6255 SHARLANDS AVE
Second Line :
City : RENO
State : NV
Zip : 89523-2882
Country : US
Telephone Number : 775-770-6672
Fax Number : 775-770-6675
Authorized Official
Title or Position : CEO/AO
Name : HELEN LIDHOLM
Credential :
Telephone Number : 775-770-3230
Provider Enumeration Date : 07/30/2015
Last Update Date : 12/23/2015

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Directions to “SAINT MARY'S MEDICAL GROUP INC ” Practice Location

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