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General NPI Number Information
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NPI Number | 1285145789
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Entity Type | Organization
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Legal Business Name | EXPRESS AT NORTHSIDE LLC
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Dates
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Enumeration Date | 10/24/2017
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Last Update Date | 09/19/2025
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Provider Practice Location Address
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Address Line | 296 NORTHSIDE DR SW
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City | ATLANTA
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State | GA
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Zip | 30313-1228
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Country | US
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Telephone | 404-549-7762
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Fax | 404-549-7625
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Provider Business Mailing Address
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Address Line | 296 NORTHSIDE DR SW
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City | ATLANTA
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State | GA
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Zip | 30313-1228
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Country | US
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Telephone | 404-549-7762
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Fax | 404-549-7625
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Authorized Official
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Title or Position | MEMBER
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Name | KETAN TRIVEDI
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Credential |
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Telephone | 678-205-7038
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PHRE010415
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License Number State | GA
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