Organization
CANTON NORTHSIDE PHARMACY INC
Active
Other names
NORTHSIDE PHARMACY WALESKA
Organization subpart
No
Provider details
NPI number
Authorized official
DARRELL CHESTER RPH (PRESIDENT)
(770) 479-2171
Entity
Organization
Contact information
Practice address
6824 REINHARDT COLLEGE PKWY, WALESKA, GA 30183-3266
(770) 479-2172
(770) 479-2249
Mailing address
PO BOX 1029, WALESKA, GA 30183-1029
(770) 479-2172
(770) 720-6006
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PHRE009402
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
17876140A
—
GA
01
—
2016750
PK
—
Enumeration date
10/18/2007
Last updated
04/12/2017
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