Organization
EASTSIDE PHARMACY INC
Active
Other names
Eastside Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
SAM KHREIZAT (OWNER)
(313) 579-1755
Entity
Organization
Contact information
Practice address
11854 E WARREN AVE, DETROIT, MI 48214-1664
(313) 579-1755
(313) 579-2067
Mailing address
11854 E WARREN AVE, DETROIT, MI 48214-1664
(313) 579-1755
(313) 579-2067
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
5301009095
MI
3336C0004X
Compounding Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2120128
PK
—
Enumeration date
05/07/2009
Last updated
11/13/2014
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