1083711022 NPI number — WESTSIDE PHARMACY, INC.

Table of content: (NPI 1083711022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083711022 NPI number — WESTSIDE PHARMACY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTSIDE PHARMACY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083711022
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
775 WEST AVE
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
CARTERSVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30120-3481
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-387-3455
Provider Business Mailing Address Fax Number:
770-387-3465

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
775 WEST AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
CARTERSVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30120-3481
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-387-3455
Provider Business Practice Location Address Fax Number:
770-387-3465
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEXTER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
770-387-3455

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  PHRE008729 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0008141736C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1151048 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".




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