Provider Demographics
NPI:1841302767
Name:EASTSIDE PHARMACY ASSOCIATES, LTD
Entity type:Organization
Organization Name:EASTSIDE PHARMACY ASSOCIATES, LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:C
Authorized Official - Last Name:HEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:608-221-8151
Mailing Address - Street 1:4205 MONONA DR
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53716-1663
Mailing Address - Country:US
Mailing Address - Phone:608-221-8151
Mailing Address - Fax:608-221-4682
Practice Address - Street 1:4502 MONONA DR
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53716-1051
Practice Address - Country:US
Practice Address - Phone:608-221-8151
Practice Address - Fax:608-221-4682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8942-042333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5117014OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WI33046300Medicaid
WI33046300Medicaid
FM1602499OtherDEA #
WI5238950001Medicare NSC