Basic Information
| Provider Information | |||||||||
| NPI: | 1336363456 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHSIDE MENTAL HEALTH CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHSIDE MENTAL HEALTH HOSPITAL, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12512 BRUCE B DOWNS BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336129209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139778700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12512 BRUCE B DOWNS BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336129209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139778700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FUMEA | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 8139778700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | PH6478 | FL | N | Agencies | Community/Behavioral Health | 251S00000X | PH8142 | FL | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | PH8142 | 01 | FL | COMMUNITY PHARMACY | OTHER | PH6478 | 01 | FL | INSTITUTIONAL CLASS PHARM | OTHER |