Provider Demographics
NPI:1710381694
Name:SOUTHSHORE PHARMACY, INC.
Entity Type:Organization
Organization Name:SOUTHSHORE PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:FLAX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-712-3064
Mailing Address - Street 1:13127 KINGS LAKE DR.
Mailing Address - Street 2:UNIT 102
Mailing Address - City:GIBSONTON
Mailing Address - State:FL
Mailing Address - Zip Code:33534-3958
Mailing Address - Country:US
Mailing Address - Phone:813-672-9600
Mailing Address - Fax:813-613-1968
Practice Address - Street 1:13127 KINGS LAKE DR.
Practice Address - Street 2:UNIT 102
Practice Address - City:GIBSONTON
Practice Address - State:FL
Practice Address - Zip Code:33534-3958
Practice Address - Country:US
Practice Address - Phone:813-672-9600
Practice Address - Fax:813-613-1968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-21
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy