Healthcare Provider Details

I. General information

NPI: 1285738237
Provider Name (Legal Business Name): NORTHSIDE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 02/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 E SAINT CLAIR ST
VINCENNES IN
47591-4853
US

IV. Provider business mailing address

1160 E SAINT CLAIR ST
VINCENNES IN
47591-4853
US

V. Phone/Fax

Practice location:
  • Phone: 812-882-1064
  • Fax: 812-882-4004
Mailing address:
  • Phone: 812-882-1064
  • Fax: 812-882-4004

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 Number60002352A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ROBERT PALMER
Title or Position: PRESIDENT
Credential: RPH
Phone: 812-882-1064