Healthcare Provider Details

I. General information

NPI: 1326007089
Provider Name (Legal Business Name): NORTHSIDE HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 01/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 COLISEUM DR
MACON GA
31217-3865
US

IV. Provider business mailing address

PHARMACY LOCK BOX PO BOX 935685
ATLANTA GA
31193-0001
US

V. Phone/Fax

Practice location:
  • Phone: 478-741-8599
  • Fax: 478-741-8598
Mailing address:
  • Phone: 404-851-2368
  • Fax:

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 NumberPHRE008936
License Number StateGA

VIII. Authorized Official

Name: JUDY GARDNER
Title or Position: PHARMACY DIRECTOR
Credential:
Phone: 404-851-6793