Provider Demographics
NPI:1386087229
Name:NORTH SHORE PHARMACY LLC
Entity type:Organization
Organization Name:NORTH SHORE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-710-3471
Mailing Address - Street 1:113 STARGRASS
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SPRING BRANCH
Mailing Address - State:TX
Mailing Address - Zip Code:78070-5164
Mailing Address - Country:US
Mailing Address - Phone:830-214-2920
Mailing Address - Fax:830-935-4532
Practice Address - Street 1:113 STARGRASS STE 100
Practice Address - Street 2:
Practice Address - City:SPRING BRANCH
Practice Address - State:TX
Practice Address - Zip Code:78070-5165
Practice Address - Country:US
Practice Address - Phone:830-214-2920
Practice Address - Fax:830-935-4532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-10
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TX286403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139811OtherPK