Provider Demographics
NPI:1104990621
Name:OCEAN SIDE PHARMACY
Entity type:Organization
Organization Name:OCEAN SIDE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRIE
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SESKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-465-1118
Mailing Address - Street 1:1118 COLONNADES DR
Mailing Address - Street 2:
Mailing Address - City:FT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34949-3063
Mailing Address - Country:US
Mailing Address - Phone:772-465-1118
Mailing Address - Fax:772-465-2426
Practice Address - Street 1:1118 COLONNADES DR
Practice Address - Street 2:
Practice Address - City:FT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34949-3063
Practice Address - Country:US
Practice Address - Phone:772-465-1118
Practice Address - Fax:772-465-2426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102373000Medicaid