| Name: | Eastside Pharmacy and Custom Compounding, Inc. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Corporation |
| Status: | Exists |
| Date of registration: | 01 Sep 2006 (18 years ago) |
| Entity Number: | 000-248-998 |
| Register Number: | 000248998 |
| County: | Limestone |
| Place of Formation: | Limestone County |
| Principal Address: | ATHENS, AL |
| Registered Office Street Address: | 2387 SOUTH HINE STATHENS, AL 35611 |
| Registered Office Street Address ZIP Code: | 35611 |
| Authorized Capital: | $1,000 |
Activities
PHARMACY
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1881884161 | 2007-08-01 | 2021-03-23 | 1406 LINDSAY LANE SOUTH, SUITE A, ATHENS, AL, 35613, US | 1406 LINDSAY LANE SOUTH, SUITE A, ATHENS, AL, 35613, US | |||||||||||||||||||||||||||||
|
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| Phone | +1 256-233-7070 |
| Fax | 2562338891 |
Authorized person
| Name | MONIQUE D. CANNON |
| Role | PRESIDENT |
| Phone | 2562337070 |
Taxonomy
| Taxonomy Code | 332B00000X - Durable Medical Equipment & Medical Supplies |
| Is Primary | No |
| Taxonomy Code | 3336C0003X - Community/Retail Pharmacy |
| License Number | 112977 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 100039186 |
| State | AL |
| Name | Role |
|---|---|
| CANNON, BILLY R SR | Agent |
| Name | Role | Address |
|---|---|---|
| JONES, D ASHLEY | Incorporator | 100 WASHINGTON STREET STE 100HUNTSVILLE, AL 35801 |
Date of last update: 02 Aug 2024
Sources: Alabama Secretary of State
