Provider Demographics
NPI:1902228067
Name:NORTHSIDE PHARMACY, LLC
Entity Type:Organization
Organization Name:NORTHSIDE PHARMACY, LLC
Other - Org Name:GLOBAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:B
Authorized Official - Last Name:SOUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-486-3197
Mailing Address - Street 1:922 20TH ST
Mailing Address - Street 2:
Mailing Address - City:HALEYVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35594
Mailing Address - Country:US
Mailing Address - Phone:205-487-0623
Mailing Address - Fax:205-486-3198
Practice Address - Street 1:922 20TH ST
Practice Address - Street 2:
Practice Address - City:HALEYVILLE
Practice Address - State:AL
Practice Address - Zip Code:35594
Practice Address - Country:US
Practice Address - Phone:205-486-3197
Practice Address - Fax:205-486-3198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1142693336C0003X
AL3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2142376OtherPK