Provider Demographics
NPI:1861403990
Name:SHORE HEALTH SVC INC
Entity type:Organization
Organization Name:SHORE HEALTH SVC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRCTR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-414-8667
Mailing Address - Street 1:9507 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:NASSAWADOX
Mailing Address - State:VA
Mailing Address - Zip Code:23413
Mailing Address - Country:US
Mailing Address - Phone:757-414-8781
Mailing Address - Fax:757-442-6295
Practice Address - Street 1:9507 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:NASSAWADOX
Practice Address - State:VA
Practice Address - Zip Code:23413
Practice Address - Country:US
Practice Address - Phone:757-414-8781
Practice Address - Fax:757-442-6295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010012243336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2103118OtherPK
VA4900375Medicaid