Provider Demographics
NPI:1336363456
Name:NORTHSIDE MENTAL HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:NORTHSIDE MENTAL HEALTH CENTER, INC.
Other - Org Name:NORTHSIDE MENTAL HEALTH HOSPITAL, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:FUMEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-977-8700
Mailing Address - Street 1:12512 BRUCE B DOWNS BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-9209
Mailing Address - Country:US
Mailing Address - Phone:813-977-8700
Mailing Address - Fax:
Practice Address - Street 1:12512 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9209
Practice Address - Country:US
Practice Address - Phone:813-977-8700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH6478251S00000X
FLPH8142251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPH8142OtherCOMMUNITY PHARMACY
FLPH6478OtherINSTITUTIONAL CLASS PHARM