Provider Demographics
NPI:1023614724
Name:NORTHTOWN PHARMACY LLC
Entity type:Organization
Organization Name:NORTHTOWN PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:601-665-4694
Mailing Address - Street 1:6220 OLD CANTON RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-2924
Mailing Address - Country:US
Mailing Address - Phone:601-665-4694
Mailing Address - Fax:769-333-9173
Practice Address - Street 1:6220 OLD CANTON RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-2924
Practice Address - Country:US
Practice Address - Phone:601-665-4694
Practice Address - Fax:769-333-9173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-08
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy