Provider Demographics
NPI:1770952491
Name:NORTHSIDE PHARMACY LLC
Entity type:Organization
Organization Name:NORTHSIDE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SHUNTELLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-940-0424
Mailing Address - Street 1:5201 HARRISBURG BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77011-4229
Mailing Address - Country:US
Mailing Address - Phone:832-940-0424
Mailing Address - Fax:832-940-0415
Practice Address - Street 1:5201 HARRISBURG BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77011-4229
Practice Address - Country:US
Practice Address - Phone:832-940-0424
Practice Address - Fax:832-940-0415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-23
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
TX30070333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149490Medicaid