Provider Demographics
NPI:1457493801
Name:SEASIDE DRUGS INC
Entity Type:Organization
Organization Name:SEASIDE DRUGS INC
Other - Org Name:ST. SIMONS DRUG CO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:912-638-8676
Mailing Address - Street 1:1627 FREDERICA RD # 10
Mailing Address - Street 2:P. O. BOX 2629
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-2528
Mailing Address - Country:US
Mailing Address - Phone:912-638-8676
Mailing Address - Fax:
Practice Address - Street 1:1627 FREDERICA RD # 10
Practice Address - Street 2:
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-2528
Practice Address - Country:US
Practice Address - Phone:912-638-8676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE002675183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00787234AMedicaid
1131983OtherNABP
1131983OtherNABP
4063950001Medicare ID - Type Unspecified