Provider Demographics
NPI:1417197567
Name:SAINT-MARK ENTERPRISES 106 LLC
Entity type:Organization
Organization Name:SAINT-MARK ENTERPRISES 106 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-518-2427
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-0098
Mailing Address - Country:US
Mailing Address - Phone:314-518-2427
Mailing Address - Fax:
Practice Address - Street 1:207 PROFESSIONAL WAY
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-4404
Practice Address - Country:US
Practice Address - Phone:360-426-4272
Practice Address - Fax:360-426-6977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-03
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6032221Medicaid
WA6229710001Medicare NSC
WAG8881421Medicare PIN