Provider Demographics
NPI:1326007089
Name:NORTHSIDE HOSPITAL, INC.
Entity Type:Organization
Organization Name:NORTHSIDE HOSPITAL, INC.
Other - Org Name:THE PHARMACY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-851-6793
Mailing Address - Street 1:PHARMACY LOCK BOX
Mailing Address - Street 2:PO BOX 935685
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-0001
Mailing Address - Country:US
Mailing Address - Phone:404-851-2368
Mailing Address - Fax:
Practice Address - Street 1:308 COLISEUM DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3865
Practice Address - Country:US
Practice Address - Phone:478-741-8599
Practice Address - Fax:478-741-8598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0089363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2138816OtherPK
2138816OtherPK