Provider Demographics
NPI:1104919216
Name:ST. MARIE CLINIC, P.A.
Entity type:Organization
Organization Name:ST. MARIE CLINIC, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-585-7401
Mailing Address - Street 1:305 E EXPRESSWAY 83
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-5560
Mailing Address - Country:US
Mailing Address - Phone:956-585-7401
Mailing Address - Fax:956-580-1788
Practice Address - Street 1:305 E EXPRESSWAY 83
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-5560
Practice Address - Country:US
Practice Address - Phone:956-585-2009
Practice Address - Fax:956-583-5833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45-373803336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145560OtherVENDOR DRUG NUMBER
TX45-37380OtherNCPDP NUMBER