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General NPI Number Information
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NPI Number | 1093860280
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Entity Type | Organization
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Legal Business Name | NORTHSIDE PHARMACY, INC.
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Dates
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Enumeration Date | 01/25/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 440 CHARTER BLVD SUITE 1107
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City | MACON
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State | GA
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Zip | 31210-4857
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Country | US
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Telephone | 478-474-6767
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Fax |
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Provider Business Mailing Address
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Address Line | 440 CHARTER BLVD SUITE 1107
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City | MACON
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State | GA
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Zip | 31210-4857
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Country | US
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Telephone | 478-474-6767
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RICKI A OLIVER
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Credential |
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Telephone | 478-474-6767
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 006380
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License Number State | GA
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