1881884161 NPI number — EASTSIDE PHARMACY AND CUSTOM COMPOUNDING, INC.

Table of content: (NPI 1881884161)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881884161 NPI number — EASTSIDE PHARMACY AND CUSTOM COMPOUNDING, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTSIDE PHARMACY AND CUSTOM COMPOUNDING, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881884161
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1406 LINDSAY LANE SOUTH
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-233-7070
Provider Business Mailing Address Fax Number:
256-233-8891

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1406 LINDSAY LANE SOUTH
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-233-7070
Provider Business Practice Location Address Fax Number:
256-233-8891
Provider Enumeration Date:
08/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CANNON
Authorized Official First Name:
MONIQUE
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
256-233-7070

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 112977 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100039186 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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