Provider Demographics
NPI:1386823573
Name:SHORELINE MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:SHORELINE MEDICAL SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:COURTRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:860-437-8800
Mailing Address - Street 1:27 FAIR HARBOUR PL
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4710
Mailing Address - Country:US
Mailing Address - Phone:860-437-8800
Mailing Address - Fax:860-447-9930
Practice Address - Street 1:27 FAIR HARBOUR PL
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4710
Practice Address - Country:US
Practice Address - Phone:860-437-8800
Practice Address - Fax:860-447-9930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT41109232001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies