=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457493801
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEASIDE DRUGS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2007
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1627 FREDERICA RD # 10
-----------------------------------------------------
City | ST SIMONS ISLAND
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31522-2528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-638-8676
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1627 FREDERICA RD # 10 P. O. BOX 2629
-----------------------------------------------------
City | ST SIMONS ISLAND
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31522-2528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-638-8676
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. THOMAS E. BRYAN JR.
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 912-638-8676
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PHRE002675
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------