Healthcare Provider Details

I. General information

NPI: 1972890531
Provider Name (Legal Business Name): SHOREVAX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2011
Last Update Date: 09/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2175 HIGHWAY 35
SEA GIRT NJ
08750-1009
US

IV. Provider business mailing address

2175 HIGHWAY 35
SEA GIRT NJ
08750-1009
US

V. Phone/Fax

Practice location:
  • Phone: 732-974-2929
  • Fax:
Mailing address:
  • Phone: 732-974-2929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number State

VIII. Authorized Official

Name: FRANK L FARIELLO
Title or Position: PARTNER
Credential:
Phone: 732-974-2929