Provider Demographics
NPI:1376060798
Name:EASTERN SHORE PHARMACY, LLC
Entity Type:Organization
Organization Name:EASTERN SHORE PHARMACY, LLC
Other - Org Name:EASTERN SHORE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:GIFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:205-529-6654
Mailing Address - Street 1:20489 STATE HWY 181
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532
Mailing Address - Country:US
Mailing Address - Phone:251-928-9073
Mailing Address - Fax:251-928-9075
Practice Address - Street 1:20489 STATE HIGHWAY 181
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-4369
Practice Address - Country:US
Practice Address - Phone:251-928-9073
Practice Address - Fax:251-928-9075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-25
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1147393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL209787Medicaid