Provider Demographics
NPI:1225085889
Name:SEASIDE PHARMACEUTICAL INC
Entity Type:Organization
Organization Name:SEASIDE PHARMACEUTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:STANLEY
Authorized Official - Last Name:TRETHAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:912-554-8220
Mailing Address - Street 1:1104 FOUNTAIN PARK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4758
Mailing Address - Country:US
Mailing Address - Phone:912-554-8220
Mailing Address - Fax:912-554-8221
Practice Address - Street 1:1104 FOUNTAIN PARK CIRCLE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4758
Practice Address - Country:US
Practice Address - Phone:912-554-8220
Practice Address - Fax:912-554-8221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH020213183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11639OtherOCCUPATIONAL TAX LICENSE
GAPHHH000002OtherPHARMACY LICENSE
GA407152969AMedicaid
GA407152969AMedicaid
GA11639OtherOCCUPATIONAL TAX LICENSE
GA407152969AMedicaid