Provider Demographics
NPI:1801417480
Name:NORTHSIDE HOSPITAL INC
Entity Type:Organization
Organization Name:NORTHSIDE HOSPITAL INC
Other - Org Name:NORTHSIDE HOSPITAL GWINNETT OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, PHARMACEUTICAL SERVICES
Authorized Official - Prefix:
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
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1606
Mailing Address - Country:US
Mailing Address - Phone:404-851-8000
Mailing Address - Fax:
Practice Address - Street 1:1000 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7694
Practice Address - Country:US
Practice Address - Phone:678-312-4233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-05
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy