Provider Demographics
NPI:1487653283
Name:NORTHSIDE HOSPITAL
Entity Type:Organization
Organization Name:NORTHSIDE HOSPITAL
Other - Org Name:NORTHSIDE FORSYTH HOME CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MRS
Authorized Official - First Name:RAE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BENTON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:770-844-3291
Mailing Address - Street 1:1200 NORTHSIDE FORSYTH DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7659
Mailing Address - Country:US
Mailing Address - Phone:770-844-3396
Mailing Address - Fax:770-844-3397
Practice Address - Street 1:1200 NORTHSIDE FORSYTH DR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7659
Practice Address - Country:US
Practice Address - Phone:770-844-3396
Practice Address - Fax:770-844-3397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE007472333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1151404OtherNABP AKA NCPDP#