Provider Demographics
NPI:1871737304
Name:NORTHSIDE PHARMACY INC
Entity type:Organization
Organization Name:NORTHSIDE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT,PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:AYRES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:410-398-3784
Mailing Address - Street 1:707 N BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-5314
Mailing Address - Country:US
Mailing Address - Phone:410-398-3784
Mailing Address - Fax:410-398-3306
Practice Address - Street 1:707 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-5314
Practice Address - Country:US
Practice Address - Phone:410-398-3784
Practice Address - Fax:410-398-3306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-28
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
MDP062603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD021969000Medicaid
2119888OtherPK