Provider Demographics
NPI:1053670844
Name:NORTHSIDE APOTHECARY LLC
Entity Type:Organization
Organization Name:NORTHSIDE APOTHECARY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:HELMS
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:205-814-9284
Mailing Address - Street 1:70 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:PELL CITY
Mailing Address - State:AL
Mailing Address - Zip Code:35125-9314
Mailing Address - Country:US
Mailing Address - Phone:205-814-9284
Mailing Address - Fax:205-338-0865
Practice Address - Street 1:70 PLAZA DRIVE
Practice Address - Street 2:
Practice Address - City:PELL CITY
Practice Address - State:AL
Practice Address - Zip Code:35125-9314
Practice Address - Country:US
Practice Address - Phone:205-814-9284
Practice Address - Fax:205-338-0865
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INRI MEDICAL ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-14
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL143787Medicaid
AL6847310001Medicare NSC