Provider Demographics
NPI:1164839577
Name:TRUDAL, LLC
Entity Type:Organization
Organization Name:TRUDAL, LLC
Other - Org Name:EASTSIDE FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:DUKE
Authorized Official - Last Name:DALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-807-0137
Mailing Address - Street 1:3896 RIVERBANK DR SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-2587
Mailing Address - Country:US
Mailing Address - Phone:404-642-8578
Mailing Address - Fax:
Practice Address - Street 1:1795 PRESIDENTIAL CIR
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-5644
Practice Address - Country:US
Practice Address - Phone:770-807-0137
Practice Address - Fax:770-696-9374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-17
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0100503336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy