Provider Demographics
NPI:1629519301
Name:NORTHSIDE PHARMACY
Entity Type:Organization
Organization Name:NORTHSIDE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:FRENCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-368-8340
Mailing Address - Street 1:201 E FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMERVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71241-2956
Mailing Address - Country:US
Mailing Address - Phone:318-368-8340
Mailing Address - Fax:318-368-7851
Practice Address - Street 1:201 E FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:FARMERVILLE
Practice Address - State:LA
Practice Address - Zip Code:71241-2956
Practice Address - Country:US
Practice Address - Phone:318-368-8340
Practice Address - Fax:318-368-7851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA43343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1273961Medicaid