1124386123 NPI number — SHORELINE PHARMACEUTICALS INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124386123 NPI number — SHORELINE PHARMACEUTICALS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHORELINE PHARMACEUTICALS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124386123
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18375 VENTURA BLVD STE 501
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TARZANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91356-4218
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-464-9170
Provider Business Mailing Address Fax Number:
310-464-9171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16530 VENTURA BLVD STE 610
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENCINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91436-5042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-464-9170
Provider Business Practice Location Address Fax Number:
310-464-9171
Provider Enumeration Date:
04/26/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WALK
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
310-464-9170

Provider Taxonomy Codes

  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: PHY51832 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2136134 . This is a "PK" identifier . This identifiers is of the category "OTHER".