Provider Demographics
NPI:1124386123
Name:SHORELINE PHARMACEUTICALS INC
Entity Type:Organization
Organization Name:SHORELINE PHARMACEUTICALS INC
Other - Org Name:SHORELINE PHARMACEUTICALS, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:WALK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-464-9170
Mailing Address - Street 1:18375 VENTURA BLVD STE 501
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-4218
Mailing Address - Country:US
Mailing Address - Phone:310-464-9170
Mailing Address - Fax:310-464-9171
Practice Address - Street 1:16530 VENTURA BLVD STE 610
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-5042
Practice Address - Country:US
Practice Address - Phone:310-464-9170
Practice Address - Fax:310-464-9171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-26
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0003X, 3336C0004X, 3336L0003X
CAPHY518323336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2136134OtherPK