Provider Demographics
NPI:1588939425
Name:ST MARYS PHARMACY LLC
Entity type:Organization
Organization Name:ST MARYS PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST INCHARGE
Authorized Official - Prefix:
Authorized Official - First Name:TANUJA
Authorized Official - Middle Name:
Authorized Official - Last Name:KATTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-768-9117
Mailing Address - Street 1:25482 POINT LOOKOUT RD
Mailing Address - Street 2:BUILDING 2 UNIT 203C
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-3895
Mailing Address - Country:US
Mailing Address - Phone:301-475-2025
Mailing Address - Fax:301-475-2026
Practice Address - Street 1:25482 POINT LOOKOUT RD BLDG 2
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-3895
Practice Address - Country:US
Practice Address - Phone:301-475-2025
Practice Address - Fax:301-475-2026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-10
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MD056803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134609OtherPK
MD6972170001Medicare NSC