Provider Demographics
NPI:1134441686
Name:SHORE PHARMACEUTICAL PROVIDERS
Entity type:Organization
Organization Name:SHORE PHARMACEUTICAL PROVIDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-938-8080
Mailing Address - Street 1:24812 82ND AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEROSE
Mailing Address - State:NY
Mailing Address - Zip Code:11426-2502
Mailing Address - Country:US
Mailing Address - Phone:718-347-4844
Mailing Address - Fax:
Practice Address - Street 1:24812 82ND AVE
Practice Address - Street 2:
Practice Address - City:BELLEROSE
Practice Address - State:NY
Practice Address - Zip Code:11426-2502
Practice Address - Country:US
Practice Address - Phone:718-347-4844
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OMNICAREESC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-25
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33065302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization