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General NPI Number Information
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NPI Number | 1255676326
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Entity Type | Organization
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Legal Business Name | EASTLAKE PHARMACY INC
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Dates
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Enumeration Date | 11/30/2012
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Last Update Date | 11/30/2012
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Provider Practice Location Address
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Address Line | 1308 GLENWOOD AVE SE
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City | ATLANTA
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State | GA
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Zip | 30316-2077
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Country | US
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Telephone | 770-593-8688
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Fax |
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Provider Business Mailing Address
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Address Line | 4141 BROOKS MILL DR
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City | LITHONIA
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State | GA
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Zip | 30038-4144
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Country | US
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Telephone | 678-357-1044
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Fax |
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Authorized Official
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Title or Position | OWNER PHARMACIST-IN-CHARGE
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Name | THOMAS JUSU
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Credential |
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Telephone | 678-357-1044
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PHRE009881
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License Number State | GA
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