Provider Demographics
NPI:1952452930
Name:NORTHSHORE DISCOUNT PHARMACY INC
Entity Type:Organization
Organization Name:NORTHSHORE DISCOUNT PHARMACY INC
Other - Org Name:NORTHSHORE DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:WENDLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-403-8662
Mailing Address - Street 1:130 SUN VALLEY ACRES
Mailing Address - Street 2:
Mailing Address - City:POPLARVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39470-6269
Mailing Address - Country:US
Mailing Address - Phone:601-403-8662
Mailing Address - Fax:601-795-0497
Practice Address - Street 1:680 ROBERT BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-1648
Practice Address - Country:US
Practice Address - Phone:985-641-5585
Practice Address - Fax:985-641-2314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
LA3721IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1264598Medicaid
1927586OtherNCPDP PROVIDER IDENTIFICATION NUMBER