Organization
EASTSIDE PHARMACY AND CUSTOM COMPOUNDING, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MONIQUE D. CANNON PHARMD (PRESIDENT)
(256) 233-7070
Entity
Organization
Contact information
Practice address
1406 LINDSAY LANE SOUTH, SUITE A, ATHENS, AL 35613
(256) 233-7070
(256) 233-8891
Mailing address
1406 LINDSAY LANE SOUTH, SUITE A, ATHENS, AL 35613
(256) 233-7070
(256) 233-8891
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
112977
AL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100039186
—
AL
Enumeration date
08/01/2007
Last updated
03/23/2021
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