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NPI Code Detail

MEDICARE: CANTON NORTHSIDE PHARMACY INC

MEDICARE: CANTON NORTHSIDE PHARMACY INC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1332B00000XDurable Medical Equipment & Medical Supplies
2333600000XPharmacy
33336C0003XCommunity/Retail Pharmacy002901GA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
22012090OTHERPK
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1861492761
Entity Type Code : Organization
Provider Name (Legal Business Name) : CANTON NORTHSIDE PHARMACY INC
Provider Business Mailing Address
First Line : PO BOX 4460
Second Line :
City : CANTON
State : GA
Zip : 30114-0200
Country : US
Telephone Number : 770-479-2171
Fax Number : 770-720-6006
Provider Business Practice Location Address
First Line : 170 MARIETTA HWY
Second Line :
City : CANTON
State : GA
Zip : 30114-2303
Country : US
Telephone Number : 770-479-2171
Fax Number : 770-720-6006
Authorized Official
Title or Position : PRES
Name : DARRELL CHESTER
Credential :
Telephone Number : 770-479-2171
Provider Enumeration Date : 07/21/2005
Last Update Date : 09/19/2025

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Directions to “CANTON NORTHSIDE PHARMACY INC ” Practice Location

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