Provider Demographics
NPI:1871780270
Name:NORTHSIDE PHARMACY GROUP, INC.
Entity type:Organization
Organization Name:NORTHSIDE PHARMACY GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BEAL
Authorized Official - Middle Name:MARL
Authorized Official - Last Name:HALBROOK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:229-436-2985
Mailing Address - Street 1:2007 GILLIONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-3139
Mailing Address - Country:US
Mailing Address - Phone:229-436-2985
Mailing Address - Fax:229-436-2987
Practice Address - Street 1:2007 GILLIONVILLE RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-3139
Practice Address - Country:US
Practice Address - Phone:229-436-2985
Practice Address - Fax:229-436-2987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-29
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPENDING3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy