Provider Demographics
NPI:1417931973
Name:NORTHSIDE HOSPITAL, INC.
Entity Type:Organization
Organization Name:NORTHSIDE HOSPITAL, INC.
Other - Org Name:NORTHSIDE HOSPTIAL PHARMACY AT MEDICAL TOWER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:404-851-6793
Mailing Address - Street 1:5670 PEACHTREE DUNWOODY RD
Mailing Address - Street 2:SUITE 810
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1699
Mailing Address - Country:US
Mailing Address - Phone:404-851-6310
Mailing Address - Fax:404-851-6386
Practice Address - Street 1:5670 PEACHTREE DUNWOODY RD
Practice Address - Street 2:SUITE 810
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1699
Practice Address - Country:US
Practice Address - Phone:404-851-6310
Practice Address - Fax:404-851-6386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0089973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2016153OtherPK