Eastside Pharmacy and Custom Compounding, Inc.

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

112977 Issued in AL

Legal business name

EASTSIDE PHARMACY AND CUSTOM COMPOUNDING, INC.

Practice address

1406 Lindsay Lane South
Suite a
Athens, AL 35613

Phone

(256) 233-7070

Fax

(256) 233-8891

NPI assigned

Aug 1, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Monique D. Cannon, PHARMDNPI 1659441541

Title

President

Phone

(256) 233-7070

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in AL2 enrollments

Enrollment records 2

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Medicare medical equipment & supply locations

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

• Hometown Pharmacy of Limestone County, LLC

  • Community/Retail Pharmacy
  • Athens, AL
  • NPI 1497176564

  Member Of

  NPD member

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Monique D. Cannon, PHARM.D.

  • Pharmacist
  • Athens, AL
  • NPI 1659441541
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1185926400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1616457600000",
    "number": "1881884161",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1406 LINDSAY LANE SOUTH",
            "address_2": "SUITE A",
            "city": "ATHENS",
            "state": "AL",
            "postal_code": "35613",
            "telephone_number": "256-233-7070",
            "fax_number": "256-233-8891"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1406 LINDSAY LANE SOUTH",
            "address_2": "SUITE A",
            "city": "ATHENS",
            "state": "AL",
            "postal_code": "35613",
            "telephone_number": "256-233-7070",
            "fax_number": "256-233-8891"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EASTSIDE PHARMACY AND CUSTOM COMPOUNDING, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-08-01",
        "last_updated": "2021-03-23",
        "certification_date": "2021-03-02",
        "status": "A",
        "authorized_official_last_name": "CANNON",
        "authorized_official_first_name": "MONIQUE",
        "authorized_official_middle_name": "D.",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "256-233-7070",
        "authorized_official_credential": "PHARMD"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "AL",
            "license": "112977",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100039186",
            "state": "AL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Jimmy Wayne Dunn, MD
• Rebekah Duran, MS, CCC-SLP
• Dva Healthcare Renal Care Inc (Athens Dialysis)
• East Limestone Family Dental, PC
• Eastside Family Medicine
• Caitlin Edgmon
• Christopher E. Edwards, MD
• Devin Eernisse, DC
• Ej&M Homes
• Stephanie Embry, CRNP

• Community/Retail Pharmacy in Athens, AL
• Providers in Athens, AL by specialty
• Community/Retail Pharmacy in Alabama

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 23, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.