=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477564060
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEASIDE MARINE INTRNTL DRUG CO INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2006
-----------------------------------------------------
Last Update Date | 04/19/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 595 W 7TH ST STE 207
-----------------------------------------------------
City | SAN PEDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90731-3152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-832-4363
-----------------------------------------------------
Fax | 310-548-5527
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 595 W 7TH ST STE 207
-----------------------------------------------------
City | SAN PEDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90731-3152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-832-4363
-----------------------------------------------------
Fax | 310-548-5527
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRES
-----------------------------------------------------
Name | JOSEPH SEIBERT
-----------------------------------------------------
Credential | BS PHARMACY
-----------------------------------------------------
Telephone | 310-832-4363
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY45801
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------