Provider Demographics
NPI:1255676326
Name:EASTLAKE PHARMACY INC
Entity Type:Organization
Organization Name:EASTLAKE PHARMACY INC
Other - Org Name:EASTLAKE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST-IN-CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:JUSU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-357-1044
Mailing Address - Street 1:4141 BROOKS MILL DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-4144
Mailing Address - Country:US
Mailing Address - Phone:678-357-1044
Mailing Address - Fax:
Practice Address - Street 1:1308 GLENWOOD AVE SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-2077
Practice Address - Country:US
Practice Address - Phone:770-593-8688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-30
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0098813336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1163029OtherNCPDP PROVIDER IDENTIFICATION NUMBER