Healthcare Provider Details

I. General information

NPI: 1285145789
Provider Name (Legal Business Name): EXPRESS AT NORTHSIDE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2017
Last Update Date: 09/19/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

296 NORTHSIDE DR SW
ATLANTA GA
30313-1228
US

IV. Provider business mailing address

296 NORTHSIDE DR SW
ATLANTA GA
30313-1228
US

V. Phone/Fax

Practice location:
  • Phone: 404-549-7762
  • Fax: 404-549-7625
Mailing address:
  • Phone: 404-549-7762
  • Fax: 404-549-7625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE010415
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KETAN TRIVEDI
Title or Position: MEMBER
Credential:
Phone: 678-205-7038