Canton Northside Pharmacy Inc

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

PHRE009402 Issued in GA

Legal business name

CANTON NORTHSIDE PHARMACY INC

Doing business as

Northside Pharmacy Waleska

Practice address

6824 Reinhardt College Pkwy
Waleska, GA 30183-3266

Phone

(770) 479-2172

Fax

(770) 479-2249

NPI assigned

Oct 18, 2007

Last updated

Apr 12, 2017By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Darrell Chester, RPHNPI 1700473287

Title

President

Phone

(770) 479-2171

Specialties & licenses 3

Addresses

Other identifiers 2

Other names 1

• NORTHSIDE PHARMACY WALESKA Doing business as

Medicare fee-for-service enrollment

Enrolled in GA2 enrollments

Enrollment records 2

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

• Canton Northside Pharmacy Inc

  dba Canton Northside Pharmacy

  • Community/Retail Pharmacy
  • Canton, GA
  • NPI 1861492761

  1456471721

  Same PAC ID

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

• Canton Northside Pharmacy Inc

  dba Canton Northside Pharmacy

  • Community/Retail Pharmacy
  • Canton, GA
  • NPI 1861492761

  O20111020000599

  Same enrollment

Tax ID family

Canton Northside Pharmacy2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Canton Northside Pharmacy Inc

  dba Canton Northside Pharmacy

  • Community/Retail Pharmacy
  • Canton, GA
  • NPI 1861492761
  NPD tax ID

Locations

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Darrell Chester, RPH

  • Pharmacist
  • Canton, GA
  • NPI 1700473287
  NPD (past) Authorized official
• Robert Bagwell Jr., PHARMD

  • Pharmacist
  • Canton, GA
  • NPI 1114514684
  NPD
• Phillip Taylor, RPH

  • Pharmacist
  • Waleska, GA
  • NPI 1609463124
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1192665600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1491955200000",
    "number": "1528257102",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1029",
            "city": "WALESKA",
            "state": "GA",
            "postal_code": "301831029",
            "telephone_number": "770-479-2172",
            "fax_number": "770-720-6006"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6824 REINHARDT COLLEGE PKWY",
            "city": "WALESKA",
            "state": "GA",
            "postal_code": "301833266",
            "telephone_number": "770-479-2172",
            "fax_number": "770-479-2249"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CANTON NORTHSIDE PHARMACY INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-10-18",
        "last_updated": "2017-04-12",
        "status": "A",
        "authorized_official_last_name": "CHESTER",
        "authorized_official_first_name": "DARRELL",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "770-479-2171",
        "authorized_official_credential": "RPH"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "GA",
            "license": "PHRE009402",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "17876140A",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2016750",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "NORTHSIDE PHARMACY WALESKA",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Community/Retail Pharmacy in Waleska, GA
• Providers in Waleska, GA by specialty
• Community/Retail Pharmacy in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 12, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.