=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952452930
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHSHORE DISCOUNT PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2007
-----------------------------------------------------
Last Update Date | 11/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 680 ROBERT BLVD
-----------------------------------------------------
City | SLIDELL
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70458-1648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-641-5585
-----------------------------------------------------
Fax | 985-641-2314
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 SUN VALLEY ACRES
-----------------------------------------------------
City | POPLARVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39470-6269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-403-8662
-----------------------------------------------------
Fax | 601-795-0497
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GREGORY WENDLING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-403-8662
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 3721IR
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------