Healthcare Provider Details

I. General information

NPI: 1124386123
Provider Name (Legal Business Name): SHORELINE PHARMACEUTICALS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16530 VENTURA BLVD STE 610
ENCINO CA
91436-5042
US

IV. Provider business mailing address

18375 VENTURA BLVD STE 501
TARZANA CA
91356-4218
US

V. Phone/Fax

Practice location:
  • Phone: 310-464-9170
  • Fax: 310-464-9171
Mailing address:
  • Phone: 310-464-9170
  • Fax: 310-464-9171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License NumberPHY51832
License Number StateCA

VIII. Authorized Official

Name: MATTHEW WALK
Title or Position: PRESIDENT
Credential:
Phone: 310-464-9170