Provider Demographics
NPI:1285738237
Name:NORTHSIDE PHARMACY INC
Entity type:Organization
Organization Name:NORTHSIDE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:812-882-1064
Mailing Address - Street 1:1160 E SAINT CLAIR ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-4853
Mailing Address - Country:US
Mailing Address - Phone:812-882-1064
Mailing Address - Fax:812-882-4004
Practice Address - Street 1:1160 E SAINT CLAIR ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-4853
Practice Address - Country:US
Practice Address - Phone:812-882-1064
Practice Address - Fax:812-882-4004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336H0001X, 3336L0003X
IN60002352A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1514430OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IN100177930AMedicaid
IN100177930AMedicaid