Provider Demographics
NPI:1477564060
Name:SEASIDE MARINE INTRNTL DRUG CO INC
Entity Type:Organization
Organization Name:SEASIDE MARINE INTRNTL DRUG CO INC
Other - Org Name:SEASIDE MARINE INT'L DRUG CO INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:SEIBERT
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:310-832-4363
Mailing Address - Street 1:595 W 7TH ST STE 207
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3152
Mailing Address - Country:US
Mailing Address - Phone:310-832-4363
Mailing Address - Fax:310-548-5527
Practice Address - Street 1:595 W 7TH ST STE 207
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3152
Practice Address - Country:US
Practice Address - Phone:310-832-4363
Practice Address - Fax:310-548-5527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 332B00000X
CAPHY458013336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA439760Medicaid
2001252OtherPK