=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972557171
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTSIDE PHARMACY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2006
-----------------------------------------------------
Last Update Date | 03/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 E PINE ST
-----------------------------------------------------
City | POPLAR BLUFF
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63901-5401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-686-7238
-----------------------------------------------------
Fax | 573-686-7239
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 E PINE ST
-----------------------------------------------------
City | POPLAR BLUFF
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63901-5401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-686-7238
-----------------------------------------------------
Fax | 573-686-7239
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST/OWNER
-----------------------------------------------------
Name | MR. STEPHEN KENNEDY ROWLAND
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 573-686-7238
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 621773506
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | 5573
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 5573
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------