Provider Demographics
NPI:1861839433
Name:NORTHSIDE COMMUNITY PHARMACY
Entity Type:Organization
Organization Name:NORTHSIDE COMMUNITY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YANG
Authorized Official - Middle Name:
Authorized Official - Last Name:XIONG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:612-345-7842
Mailing Address - Street 1:1501 LOWRY AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-1260
Mailing Address - Country:US
Mailing Address - Phone:612-345-7842
Mailing Address - Fax:612-353-6458
Practice Address - Street 1:1501 LOWRY AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-1260
Practice Address - Country:US
Practice Address - Phone:612-345-7842
Practice Address - Fax:612-353-6458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-22
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2641203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7157150001Medicare NSC