Provider Demographics
NPI:1750723722
Name:BAYSHORE PHARMACY
Entity type:Organization
Organization Name:BAYSHORE PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:SERRAGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-344-0410
Mailing Address - Street 1:1026 SW BAYSHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-2400
Mailing Address - Country:US
Mailing Address - Phone:772-344-0410
Mailing Address - Fax:772-344-0409
Practice Address - Street 1:1026 SW BAYSHORE BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-2400
Practice Address - Country:US
Practice Address - Phone:772-344-0410
Practice Address - Fax:772-344-0409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-19
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
FLPH267743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101097200Medicaid
2140977OtherPK