Provider Demographics
NPI:1689660243
Name:NORTHSIDE HOSPITAL PHARMACY AT MERIDIAN MARK
Entity Type:Organization
Organization Name:NORTHSIDE HOSPITAL PHARMACY AT MERIDIAN MARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:HORTON
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-459-1740
Mailing Address - Street 1:5445 MERIDIAN MARKS RD NE
Mailing Address - Street 2:STE 190
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-4763
Mailing Address - Country:US
Mailing Address - Phone:404-459-1740
Mailing Address - Fax:404-459-1745
Practice Address - Street 1:5445 MERIDIAN MARKS RD NE
Practice Address - Street 2:STE 190
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4763
Practice Address - Country:US
Practice Address - Phone:404-459-1740
Practice Address - Fax:404-459-1745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE008289333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00821796AMedicaid