Provider Demographics
NPI:1891381265
Name:CIP NORTHSIDE LLC
Entity Type:Organization
Organization Name:CIP NORTHSIDE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:CODY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:806-451-4799
Mailing Address - Street 1:1113 MURFREESBORO RD STE 106-410
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37064-1306
Mailing Address - Country:US
Mailing Address - Phone:806-451-4799
Mailing Address - Fax:325-305-0565
Practice Address - Street 1:3802 CATCLAW DR STE 2
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-8253
Practice Address - Country:US
Practice Address - Phone:806-451-4799
Practice Address - Fax:325-305-0565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy