# EASTSIDE PHARMACY AND CUSTOM COMPOUNDING, INC.

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1881884161
- **Authorized official:** MONIQUE D. CANNON PHARMD (PRESIDENT)
- **Authorized official phone:** (256) 233-7070

## Contact information

- **Practice address:** 1406 LINDSAY LANE SOUTH, SUITE A, ATHENS, AL 35613
- **Practice address phone:** (256) 233-7070
- **Practice address fax:** (256) 233-8891
- **Mailing address:** 1406 LINDSAY LANE SOUTH, SUITE A, ATHENS, AL 35613
- **Mailing address phone:** (256) 233-7070
- **Mailing address fax:** (256) 233-8891

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | NULL | — |
| 3336C0003X | Community/Retail Pharmacy | 112977 | AL | Yes |

## Other

- **Enumeration date:** 08/01/2007
- **Last updated:** 03/23/2021

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 100039186 | — | AL |