Provider Demographics
NPI:1881884161
Name:EASTSIDE PHARMACY AND CUSTOM COMPOUNDING, INC.
Entity type:Organization
Organization Name:EASTSIDE PHARMACY AND CUSTOM COMPOUNDING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:D
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:256-233-7070
Mailing Address - Street 1:1406 LINDSAY LANE SOUTH
Mailing Address - Street 2:SUITE A
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35613
Mailing Address - Country:US
Mailing Address - Phone:256-233-7070
Mailing Address - Fax:256-233-8891
Practice Address - Street 1:1406 LINDSAY LANE SOUTH
Practice Address - Street 2:SUITE A
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35613
Practice Address - Country:US
Practice Address - Phone:256-233-7070
Practice Address - Fax:256-233-8891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
AL1129773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100039186Medicaid
6077540001Medicare NSC