Provider Demographics
NPI:1497114144
Name:SOUTHSIDE SPECIALTY PHARMACY
Entity type:Organization
Organization Name:SOUTHSIDE SPECIALTY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IHAB
Authorized Official - Middle Name:
Authorized Official - Last Name:HERRAKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-242-2888
Mailing Address - Street 1:3416 OLD GREENWOOD RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3416 OLD GREENWOOD RD
Practice Address - Street 2:SUITE A
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5462
Practice Address - Country:US
Practice Address - Phone:479-242-2888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR208293336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy