Provider Demographics
NPI:1962536458
Name:NORTHSHORE DISCOUNT PHARMACY, INC
Entity type:Organization
Organization Name:NORTHSHORE DISCOUNT PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:JON
Authorized Official - Last Name:WENDLING
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:985-641-5585
Mailing Address - Street 1:680 ROBERT BLVD
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-1648
Mailing Address - Country:US
Mailing Address - Phone:985-641-5585
Mailing Address - Fax:985-641-2314
Practice Address - Street 1:680 ROBERT BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-1648
Practice Address - Country:US
Practice Address - Phone:985-641-5585
Practice Address - Fax:985-641-2314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA37213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1264598Medicaid