Provider Demographics
NPI:1003996075
Name:SHORELINE SCRIPT ALLIANCE
Entity Type:Organization
Organization Name:SHORELINE SCRIPT ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNWER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:OVERKAMP
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:616-233-9126
Mailing Address - Street 1:1425 MICHIGAN ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2027
Mailing Address - Country:US
Mailing Address - Phone:616-233-9126
Mailing Address - Fax:616-233-0556
Practice Address - Street 1:1425 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2027
Practice Address - Country:US
Practice Address - Phone:616-233-9126
Practice Address - Fax:616-233-0556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301007783183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2365333Medicaid
MI2365333Medicare ID - Type Unspecified