Basic Information
| Provider Information | |||||||||
| NPI: | 1053670844 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHSIDE APOTHECARY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 70 PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | PELL CITY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351259314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2058149284 | ||||||||
| FaxNumber: | 2053380865 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 PLAZA DRIVE | ||||||||
| Address2: | |||||||||
| City: | PELL CITY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351259314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2058149284 | ||||||||
| FaxNumber: | 2053380865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2012 | ||||||||
| LastUpdateDate: | 10/24/2013 | ||||||||
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| AuthorizedOfficialLastName: | HELMS | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2058149284 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INRI MEDICAL ASSOCIATES | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | AL | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 143787 | 05 | AL | MEDICAID |