Basic Information
| Provider Information | |||||||||
| NPI: | 1184394058 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHSIDE HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NORTHSIDE HOSPITAL PHARMACY AT MIDTOWN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 JOHNSON FERRY RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048518000 | ||||||||
| FaxNumber: | 7703930835 | ||||||||
| Practice Location | |||||||||
| Address1: | 1110 W PEACHTREE STREET NW | ||||||||
| Address2: | SUITE 340 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303093609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6787924110 | ||||||||
| FaxNumber: | 4043434635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2021 | ||||||||
| LastUpdateDate: | 11/10/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARDNER | ||||||||
| AuthorizedOfficialFirstName: | JUDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SYSTEM DIRECTOR, PHARMACEUTICAL SER | ||||||||
| AuthorizedOfficialTelephone: | 4048516793 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.