Provider Demographics
NPI:1437134970
Name:NORTHSIDE HOSPITAL, INC.
Entity type:Organization
Organization Name:NORTHSIDE HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PHARMACEUTICAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, FASHP
Authorized Official - Phone:404-851-6793
Mailing Address - Street 1:1000 JOHNSON FERRY ROAD
Mailing Address - Street 2:ATTN: JUDY GARDNER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1616
Mailing Address - Country:US
Mailing Address - Phone:404-851-6793
Mailing Address - Fax:404-851-8610
Practice Address - Street 1:650 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8707
Practice Address - Country:US
Practice Address - Phone:678-442-3642
Practice Address - Fax:770-442-3066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-07
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE008388282N00000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1147215OtherNABP OR NCPDP
GA866291AMedicaid