Provider Demographics
NPI:1861666448
Name:EASTSIDE DISCOUNT PHARMACY
Entity Type:Organization
Organization Name:EASTSIDE DISCOUNT PHARMACY
Other - Org Name:EASTSIDE DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MAHMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:FOUDOUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-433-5578
Mailing Address - Street 1:14366 GRATIOT AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48205-2307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14366 GRATIOT AVE
Practice Address - Street 2:STE 100
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-2307
Practice Address - Country:US
Practice Address - Phone:313-839-2000
Practice Address - Fax:313-839-2003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010088463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2371021OtherOTHER ID NUMBER