=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225085889
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEASIDE PHARMACEUTICAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1104 FOUNTAIN PARK CIRCLE
-----------------------------------------------------
City | BRUNSWICK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31520-4758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-554-8220
-----------------------------------------------------
Fax | 912-554-8221
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1104 FOUNTAIN PARK CIRCLE
-----------------------------------------------------
City | BRUNSWICK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31520-4758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-554-8220
-----------------------------------------------------
Fax | 912-554-8221
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | ROBERT STANLEY TRETHAWAY
-----------------------------------------------------
Credential | PHARMACIST
-----------------------------------------------------
Telephone | 912-554-8220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RPH020213
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------