=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760804397
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEASIDE PHARMACY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2014
-----------------------------------------------------
Last Update Date | 10/31/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 169 SHIRLEY AVE
-----------------------------------------------------
City | REVERE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02151-3256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-284-6525
-----------------------------------------------------
Fax | 781-284-6530
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 169 SHIRLEY AVE
-----------------------------------------------------
City | REVERE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02151-3256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-284-6525
-----------------------------------------------------
Fax | 781-284-6530
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | MRS. TU-ANH THI VO
-----------------------------------------------------
Credential | PHARMD.
-----------------------------------------------------
Telephone | 781-284-6525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------