Provider Demographics
NPI:1639178213
Name:NORTHSIDE HOSPITAL HOMECARE PHARMACY
Entity Type:Organization
Organization Name:NORTHSIDE HOSPITAL HOMECARE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MRS
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 1:1000 JOHNSON FERRY RD NE
Mailing Address - Street 2:HOMECARE PHARMACY
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1606
Mailing Address - Country:US
Mailing Address - Phone:404-851-8897
Mailing Address - Fax:404-303-3323
Practice Address - Street 1:1000 JOHNSON FERRY RD NE
Practice Address - Street 2:HOMECARE PHARMACY
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1606
Practice Address - Country:US
Practice Address - Phone:404-851-8897
Practice Address - Fax:404-303-3323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006234333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00001405DMedicaid