Provider Demographics
NPI:1528257102
Name:CANTON NORTHSIDE PHARMACY INC
Entity type:Organization
Organization Name:CANTON NORTHSIDE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHESTER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:770-479-2171
Mailing Address - Street 1:PO BOX 1029
Mailing Address - Street 2:
Mailing Address - City:WALESKA
Mailing Address - State:GA
Mailing Address - Zip Code:30183-1029
Mailing Address - Country:US
Mailing Address - Phone:770-479-2172
Mailing Address - Fax:770-720-6006
Practice Address - Street 1:6824 REINHARDT COLLEGE PKWY
Practice Address - Street 2:
Practice Address - City:WALESKA
Practice Address - State:GA
Practice Address - Zip Code:30183-3266
Practice Address - Country:US
Practice Address - Phone:770-479-2172
Practice Address - Fax:770-479-2249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
GAPHRE0094023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA17876140AMedicaid
2016750OtherPK
GA178761410AMedicaid
GA1022700003Medicare NSC