Provider Demographics
NPI:1902357130
Name:EASTSIDE PHARMACY SERVICES LLC
Entity Type:Organization
Organization Name:EASTSIDE PHARMACY SERVICES LLC
Other - Org Name:BANNER DRUG CO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHILDRESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-872-2604
Mailing Address - Street 1:308A MOCKSVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-8267
Mailing Address - Country:US
Mailing Address - Phone:704-878-6681
Mailing Address - Fax:704-878-6684
Practice Address - Street 1:308A MOCKSVILLE HWY
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-8267
Practice Address - Country:US
Practice Address - Phone:704-878-6681
Practice Address - Fax:704-878-6684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-24
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13145333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166909OtherPK