Provider Demographics
NPI:1144945221
Name:SHORE INTEGRATIVE HEALTH
Entity type:Organization
Organization Name:SHORE INTEGRATIVE HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:TALLENT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:412-523-3402
Mailing Address - Street 1:PO BOX 1207
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-8924
Mailing Address - Country:US
Mailing Address - Phone:443-339-9713
Mailing Address - Fax:
Practice Address - Street 1:508 IDLEWILD AVE STE 5
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-3834
Practice Address - Country:US
Practice Address - Phone:443-339-9713
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD10112022Medicaid