Healthcare Provider Details

I. General information

NPI: 1871737304
Provider Name (Legal Business Name): NORTHSIDE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 12/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N BRIDGE ST
ELKTON MD
21921-5314
US

IV. Provider business mailing address

707 N BRIDGE ST
ELKTON MD
21921-5314
US

V. Phone/Fax

Practice location:
  • Phone: 410-398-3784
  • Fax: 410-398-3306
Mailing address:
  • Phone: 410-398-3784
  • Fax: 410-398-3306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP06260
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DAVID AYRES
Title or Position: PRESIDENT,PIC, AO
Credential: RPH
Phone: 410-398-3784