Healthcare Provider Details

I. General information

NPI: 1942521448
Provider Name (Legal Business Name): SEASIDE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2010
Last Update Date: 06/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 SOUTH EAST CENTRAL AVE
SEASIDE PARK NJ
08752
US

IV. Provider business mailing address

410 SOUTH EAST CENTRAL AVE
SEASIDE PARK NJ
08752
US

V. Phone/Fax

Practice location:
  • Phone: 732-250-6600
  • Fax: 732-250-6601
Mailing address:
  • Phone: 732-250-6600
  • Fax: 732-250-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number28RS00704400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28RS00704400
License Number StateNJ

VIII. Authorized Official

Name: MR. KANAKIS MARKAKIS
Title or Position: PHARMACIST
Credential: R.PH.
Phone: 732-250-6600