Provider Demographics
NPI:1417553777
Name:NORTHSHORE HEALTH CENTERS, INC
Entity Type:Organization
Organization Name:NORTHSHORE HEALTH CENTERS, INC
Other - Org Name:NORTHSHORE HAMMOND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-763-8112
Mailing Address - Street 1:PO BOX 1430
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-9230
Mailing Address - Country:US
Mailing Address - Phone:219-763-8112
Mailing Address - Fax:219-764-5380
Practice Address - Street 1:1828 165TH ST STE A
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46320-2823
Practice Address - Country:US
Practice Address - Phone:219-764-5349
Practice Address - Fax:219-764-5381
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHSHORE HEALTH CENTERS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-10
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No3336C0002XSuppliersPharmacyClinic Pharmacy