Provider Demographics
NPI:1083711022
Name:WESTSIDE PHARMACY, INC.
Entity Type:Organization
Organization Name:WESTSIDE PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:DEXTER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:770-387-3455
Mailing Address - Street 1:775 WEST AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-3481
Mailing Address - Country:US
Mailing Address - Phone:770-387-3455
Mailing Address - Fax:770-387-3465
Practice Address - Street 1:775 WEST AVE
Practice Address - Street 2:SUITE C
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-3481
Practice Address - Country:US
Practice Address - Phone:770-387-3455
Practice Address - Fax:770-387-3465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE008729261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0008141736CMedicaid
1151048OtherNCPDP
1151048OtherNCPDP