Provider Demographics
NPI:1306094206
Name:ST MARYS PHARMACY INC
Entity type:Organization
Organization Name:ST MARYS PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR RETAIL PHARMACY OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-299-7553
Mailing Address - Street 1:4 RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:PA
Mailing Address - Zip Code:15857-1729
Mailing Address - Country:US
Mailing Address - Phone:814-834-3017
Mailing Address - Fax:814-834-6510
Practice Address - Street 1:190 N FRALEY ST
Practice Address - Street 2:SUITE 2
Practice Address - City:KANE
Practice Address - State:PA
Practice Address - Zip Code:16735-1165
Practice Address - Country:US
Practice Address - Phone:814-837-8500
Practice Address - Fax:814-837-8501
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENN HIGHLANDS HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-04
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336S0011X, 332B00000X, 333600000X
PAPP4818493336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2116840OtherPK
PA1007711390007Medicaid
2116840OtherPK