MEDICARE: OCEAN SIDE PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104990621
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OCEAN SIDE PHARMACY

Provider Business Mailing Address
First Line	:	1118 COLONNADES DR
Second Line	:
City	:	FT PIERCE
State	:	FL
Zip	:	34949-3063
Country	:	US
Telephone Number	:	772-465-1118
Fax Number	:	772-465-2426

Provider Business Practice Location Address
First Line	:	1118 COLONNADES DR
Second Line	:
City	:	FT PIERCE
State	:	FL
Zip	:	34949-3063
Country	:	US
Telephone Number	:	772-465-1118
Fax Number	:	772-465-2426

Authorized Official
Title or Position	:	OWNER
Name	:	MR. LARRIE DAVID SESKIN
Credential	:
Telephone Number	:	772-465-1118

Provider Enumeration Date	:	11/17/2006
Last Update Date	:	06/25/2008

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Directions to “OCEAN SIDE PHARMACY ” Practice Location

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