Organization
EASTLAKE PHARMACY INC
Active
Other names
EASTLAKE PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
THOMAS JUSU (OWNER PHARMACIST-IN-CHARGE)
(678) 357-1044
Entity
Organization
Contact information
Practice address
1308 GLENWOOD AVE SE, ATLANTA, GA 30316-2077
(770) 593-8688
Mailing address
4141 BROOKS MILL DR, LITHONIA, GA 30038-4144
(678) 357-1044
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
PHRE009881
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1163029
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
11/30/2012
Last updated
11/30/2012
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