Provider Demographics
NPI:1386741122
Name:ST. MARY HEALTH VENTURES INC
Entity type:Organization
Organization Name:ST. MARY HEALTH VENTURES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER/AO
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:MCNEALY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-491-9189
Mailing Address - Street 1:1045 ATLANTIC AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3408
Mailing Address - Country:US
Mailing Address - Phone:562-491-9799
Mailing Address - Fax:562-491-9058
Practice Address - Street 1:1045 ATLANTIC AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3408
Practice Address - Country:US
Practice Address - Phone:562-491-9799
Practice Address - Fax:562-491-9058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY410093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA410090Medicaid
1991471OtherPK