Organization
ST. MARY MEDICAL GROUP, LLC
Active
Other names
Idyllwild Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JAMES MARIO LA PONZA PHARM.D (VICE PRESIDENT/PHARMACIST-IN-CHARGE)
(951) 659-2135
Entity
Organization
Contact information
Practice address
54391 VILLAGE CENTER DR # 6, IDYLLWILD, CA 92549-9997
(951) 659-2135
Mailing address
54391 VILLAGE CENTER DR # 6, IDYLLWILD, CA 92549-9997
(951) 659-2135
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
56117
CA
3336C0003X
Community/Retail Pharmacy
PHY48585
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
PHA196710
—
CA
Enumeration date
05/17/2007
Last updated
12/26/2018
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