Provider Demographics
NPI:1447497763
Name:SAINT-MARK ENTERPRISES 1855 LLC
Entity type:Organization
Organization Name:SAINT-MARK ENTERPRISES 1855 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:
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 1:110 E OAK ST
Practice Address - Street 2:
Practice Address - City:FREDERIC
Practice Address - State:WI
Practice Address - Zip Code:54837
Practice Address - Country:US
Practice Address - Phone:715-327-4208
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-08
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI332B00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100002192Medicaid
5131331OtherNCPDP #
WI100002192Medicaid
WIWI1238Medicare PIN