Provider Demographics
NPI:1548268022
Name:BAYSIDE PHARMACY LIMITED PARTNERSHIP
Entity type:Organization
Organization Name:BAYSIDE PHARMACY LIMITED PARTNERSHIP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HIMAL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-580-1601
Mailing Address - Street 1:300 STATE ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507
Mailing Address - Country:US
Mailing Address - Phone:814-351-0026
Mailing Address - Fax:814-351-0027
Practice Address - Street 1:300 STATE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507
Practice Address - Country:US
Practice Address - Phone:814-351-0026
Practice Address - Fax:814-351-0027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP411870L333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3954547OtherNAT'L ASSN BOARD PHARM
PA103854880-0001Medicaid