Provider Demographics
NPI:1720212681
Name:EASTSIDE PHARMACY INC
Entity Type:Organization
Organization Name:EASTSIDE PHARMACY INC
Other - Org Name:EASTSIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KHREIZAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-579-1755
Mailing Address - Street 1:11854 E WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-1664
Mailing Address - Country:US
Mailing Address - Phone:313-579-1755
Mailing Address - Fax:313-579-2067
Practice Address - Street 1:11854 E WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-1664
Practice Address - Country:US
Practice Address - Phone:313-579-1755
Practice Address - Fax:313-579-2067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-07
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MI53010090953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2120128OtherPK