Provider Demographics
NPI:1285991893
Name:SAINT MARY PHARMACY LLC
Entity type:Organization
Organization Name:SAINT MARY PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-380-8700
Mailing Address - Street 1:23521 PASEO DE VALENCIA STE 115A
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3137
Mailing Address - Country:US
Mailing Address - Phone:949-586-4575
Mailing Address - Fax:949-586-4547
Practice Address - Street 1:23521 PASEO DE VALENCIA STE 115A
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3137
Practice Address - Country:US
Practice Address - Phone:949-586-4575
Practice Address - Fax:949-586-4547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-19
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA509543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134794OtherPK
6761920001Medicare NSC